INDUSTRIAL  MEDICINE 


Being  the  Papers  and  Discussions  on 
"The  Practice  of  Medicine  and  the 
Industries"  presented  at  theXXXIXth 
Annual  Meeting  of  the  American 
Academy  of  Medicine,  held  at  Atlan- 
tic City,  June  20,  1914 


Easton,  Pa.: 

American  Academy  of  Medicine  Pre» 
1915 


The  American  Academy  of  Medicine  is  not  responsible  for  the 
sentiments  exprest  in  any  paper  or  article  presented  to  it. 


INTRODUCTION. 


Following  the  custom  of  the  last  two  or  three  years  the  Amer- 
ican Academy  of  Medicine  collates  in  this  volume  the  papers  and 
discussions  of  the  principal  topic  of  discussion  at  its  last  annual 
meeting.  Notwithstanding  these  articles  have  appeared  in  the 
Bulletin  of  the  American  Academy  of  Medicine,  experience  has 
shown  that  there  is  demand  for  gathering  the  papers  into  a 
single  volume  for  convenience  of  reference. 

The  opportunity  offered  by  this  publishing  is  embraced  to  thank 
all  those  who  contributed  to  make  the  discussion  so  valuable. 
That  it  is  but  the  partial  presentation  of  the  subject  itself  does 
not  decrease  its  value  because  of  the  excellence  of  the  papers 
upon  individual  topics. 


TABLE  OF  CONTENTS. 

I.  The  Cancer  Death  Rate  in  Selected  Occupations.     By  Frederick 

L.  Hoffman,  LL.D.,  Newark,  N.  J, 7 

II.  The  Economic  Importance  of  Lead  Poisoning.  By  Alice  Hamil- 
ton, M.A.,  M.D.,  Chicago 21 

Jfc    III.  Hygiene  and  Machinery  Hazards.     By  C.  T.  Graham-Rogers, 

M.D.,  New  York  City 27 

IV.  Measuring  the  Cost  of  Child  Labor.  By  Alexander  J.  McKel- 
way,  D.D.,  Washington,  D.  C.,  and  Owen  R.  Lovejoy,  LL.D., 

New  York  City 31 

V.  Causes  of  Morbidity  and  Mortality  in  the  Industrial  Parturient 
Woman  and  Measures  for  Improvement.  By  E.  E.  Mont- 
gomery, M.D.,  LL.D.,  Philadelphia 40 

VI.  Fatigue  as  an  Element  of  Menace  to  Health  in  the  Industries. 

By  L.  Duncan  Bulkley,  A.M.,  M.D.,  New  York  City 44 

VII.  Light  in  the  Industries.     By  Edward  Jackson,  M.D.,  Denver.  .     50 

VIII.  Heat  and  Ventilation.     By  John  Roach,  Trenton,  N.  J 56 

IX.  Crowding,  in  Relation  to  the  Health  of  Working  People.     By 

Charles  Richmond  Henderson,  D.D.,  Ph.D.,  Chicago 61 

X.  How  Foods  and  Drugs  Can  Menace.     By  Winfield  Scott  Hall, 

Ph.D.,  M.D.,  Chicago 70 

XI.  Home   Surroundings.     By   Thomas    D.    Davis,    M.D.,    Ph.D., 

Pittsburgh 82 

XII.  Improper  Recreations.     By  Sherman  C.  Kingsley,  Chicago 87 

XIII.  Discussion: 

Dr.  L.  Duncan  Bulkley 92 

Mr.  Lewis  T.  Bryant 92 

Dr.  F.  L.  Hoffman 92 

Mr.  H.  W.  Jordan 93 

Dr.  C.  T.  Graham-Rogers 93 

Dr.  Helen  C.  Putnam 94 

Dr.  Edward  Jackson 95 

Dr.  John  L.  Heffron 96 

XIV.  Medical  Inspection  of  the  Industries — National,  State,  Munici- 

pal, or  Private.     By  Ray  Lyman  Wilbur,  A.M.,  M.D.,  San 

Francisco 98 

XV.  Medical    Supervision   in    Dangerous   Trades.     By    George    M. 

Price,  M.D.,  New  York  City 103 

XVI.  Prevention  of  Industrial  Accidents  and  Sickness  by  Systematic 
Inspection  of  Plant  and  Employees.     By  H.  W.  Jordan,  B.S., 

Syracuse,  N.  Y 109 

XVII.  Rules  and  Regulations  in  Operating  Plants — Carelessness  and 

Recklessness.     By  John  B.  Lowman,  M.D.,  Johnstown,  Pa..   114 


XVIII.  Health  Measures  Affecting  Factory  Employees — Some  Remarks 
on  the  Medical  Phases  of  Such*  Legislation.  By  J.  K.  Tucker- 
man,  A.B.,  M.D.,  Cleveland 126 

XIX.  Happiness  as  a  Factor  in  Efficiency.     By  Woods  Hutchinson, 

A.M.,  M.D.,  New  York  City 135 

XX.  Industrial  Injuries:     Treatment.     By  W.  L.  Estes,  A.M.,  M.D., 

South  Bethlehem,  Pa 139 

XXI.  The  Relation  of  the  Medical  Profession  to  the  Workman's  Com- 
pensation Acts  in  the  United  States.  By  Frederick  L.  Van- 
Sickle,  M.D.,  Olyphant,  Pa 145 

XXII.  Discussion: 

Dr.  T.  W.  Grayson 175 

Dr.  Helen  C.  Putnam 177 

Dr.  H.  O.  Marcy : 178 

Dr.  Thomas  Darlington 178 

Dr.  Woods  Hutchinson 179 

Dr.  T.  D.  Davis 179 

Dr.  Edward  Jackson 179 

Dr.  James  H.  McBride 180 

Mr.  John  Roach 181 

Index..  .    182 


I. 

THE  CANCER  DEATH  RATE  IN  SELECTED  OCCU- 
PATIONS. 

By  FREDERICK  L.  HOFFMAN,  LL.D.,  Statistician,  Prudential  Insurance  Company, 
Newark,  N.  J. 

A  full  discussion  of  the  occupational  aspects  of  the  cancer  prob- 
lem is  out  of  the  question  on  account  of  the  paucity  of  data  and 
the  doubtful  value  of  a  considerable  amount  of  available  statis- 
tical information.  Most  of  the  cancer  statistics  by  occupation 
fail  to  differentiate  the  organs  and  parts  of  the  body  affected, 
so  that  the  initial  seat  of  the  disease  cannot  be  correlated 
to  the  known  factors  or  conditions  producing  irritability,  or 
traumatism,  resulting  in  cancerous  growth.  Authorities  on  the 
subject  of  workmen's  compensation  for  industrial  diseases  are 
very  guarded  in  their  references  to  the  interrelation  of  accidental 
injuries  to  cancerous  growth,  excepting  such  forms  of  malignant 
disease  as  will  subsequently  be  discussed  with  the  required  brevity, 
but  in  sufficient  detail  to  emphasize  the  points  of  most  practical 
importance.  From  a  statistical  point  of  view  the  occupational 
aspects  of  the  cancer  problem  are  of  exceptional  interest  and  de- 
serving of  much  more  technical  consideration  than  has  been  given 
to  this  phase  of  the  cancer  problem  in  the  past.  The  evidence  is 
apparently  entirely  conclusive  that  specific  injuries  to  different 
parts  of  the  body,  whether  internal  or  external,  especially  injuries 
resulting  in  a  long-continued  condition  of  slight  irritability, 
may  develop  into  cancerous  growth  of  practically  every  known 
variety  and  degree  of  malignancy.  That  the  relative  mortality 
from  cancer  varies  considerably  according  to  occupation,  has 
been  established  beyond  a  question  of  reasonable  doubt  by  the 
decennial  occupation  mortality  investigations  of  the  Registrar- 
General  of  England  and  Wales.  The  classical  illustrations  of 
chimney-sweeps'  cancer  may  be  referred  to  as  an  extreme  instance 
of  an  occupation  peculiarly  liable  to  malignant  disease,  so  much 
so  that  by  far  the  greatest  excess  of  mortality  in  this  occupation, 
according  to  the  last  report  of  the  Registrar-General,  "is  at- 


8 

tributable  to  cancer,  for  which  the  comparative  figure  is  2*/4 
times  the  standard."  In  no  other  occupation  does  the  disease 
apparently  reach  such  excessive  proportions,  at  least  not  in  a  fatal 
form.  Chimney-sweeps'  cancer  is  defined  by  W.  J.  Greer  in  his 
treatise  on  "Industrial  Diseases  and  Accidents,"  as  follows: 
Epithelioma  of  the  scrotum  in  chimney-sweeps  is  believed  to  be  due  to  the 
long-continued  irritation  caused  by  the  constant  presence  of  soot  on  the 
part.  The  disease  gives  evidence  of  its  maturity  by  the  appearance  of 
warty  growths,  which  may  remain  quiescent  or  develop  into  ulcers.  These 
ulcers  progress  and  destroy  the  whole  scrotum  (purse).  The  glands  in  the 
groin  become  infected,  and  are  eventually  open,  putrefying  sores.  The 
disease  may  ulcerate  into  the  femoral  or  external  iliac  arteries  and  cause 
fatal  hemorrhage.  The  disease  is  curable  by  early  operative  removal. 

Chimney-sweeps'  cancer  in  English  experience  has  declined 
since  1890— '02  and  at  every  divisional  period  of  life.  Regardless, 
however,  of  the  fact  that  the  mortality  rate  from  cancer  has 
diminished  by  nearly  one-fourth,  chimney-sweeps  are  still  subject 
to  the  highest  fatality  from  this  disease,  although,  in  the  words 
of  the  Registrar-General,  "In  several  other  occupations,  e.  g., 
inn-servants  in  London,  brewers,  furriers,  laborers  and  seamen, 
the  mortality  does  not  fall  far  short  of  that  of  chimney-sweeps." 
Cancer  among  chimney-sweeps  is  not,  however,  as  often  assumed, 
limited  to  the  typical  form  of  so-called  "sweeps'  cancer,"  for, 
as  shown  by  the  English  experience  for  I9oo-'o2,  only  23  deaths 
were  due  to  this  form,  out  of  a  total  of  71,  or  32.39  per  cent. 
In  view  of  the  fact  that  chimney-sweeping,  by  more  or  less  identical 
methods,  is  a  well-developed  industry  in  Germany,  the  average 
number  of  workmen  employed  for  the  year  1912  being  returned 
by  the  Insurance  Association  at  6,014,  it  may  be  suggested  that 
the  possible  frequency  of  malignant  growth  among  German 
chimney-sweeps  should  be  ascertained  for  purposes  of  comparison. 

Since  the  cancer  death  rate  is  largely  a  function  of  age,  it  is 
obviously  of  the  utmost  importance  that  in  the  calculation  of 
cancer  mortality  rates  by  occupation,  the  age  factor  should  always 
be  taken  into  account.  Some  occupational  groups  have  a  very 
much  larger  proportion  of  persons  of  the  cancer  age  than  others, 
as  best  illustrated  in  the  contrast  of  clergymen  and  bookkeepers, 
clerks  and  copyists,  considered  as  a  group.  In  the  former  the 


proportion  of  population  in  1900  at  ages  45  and  over  was  45.5 
per  cent.,  against  a  proportion  of  only  14.1  per  cent,  for  the  latter. 
Crude  death  rates  based  upon  groups  so  fundamentally  at  variance 
with  each  other,  are  obviously  erroneous  and  often  seriously 
misleading.  In  the  English  experience,  for  illustration,  the  crude 
cancer  death  rate  for  clergymen  is  163.1  per  100,000  of  population, 
whereas  for  school  teachers  the  crude  rate  was  only  52.5.  When 
the  required  correction  is  made  for  age,  the  rates  for  the  two 
groups  are  in  close  conformity,  being  respectively,  for  clergymen 
87.3,  and  for  school  teachers  90.1.  Equally  striking  is  the  result 
of  a  correction  for  age  in  the  cancer  death  rate  of  English  railway 
engine-drivers  and  stokers,  which  is  increased  from  a  crude  death 
rate  of  41.9  to  85.3.  When  the  rates  are  corrected  for  age,  the 
relative  incidence  of  cancer  in  different  occupations  becomes 
a  more  trustworthy  indication  of  specific  liability,  although  a 
further  correction  for  the  organs  and  parts  of  the  body  affected 
would  be  necessary  to  establish  the  true  causal  relationship  ex- 
isting between  specific  employments  and  specific  instances  of 
malignant  growth.  According  to  the  English  experience  for 
I90o-'o2  (no  later  data  having  been  published  and  no  corre- 
sponding data  being  extant  for  the  United  States)  for  a  few  se- 
lected occupations  with  excessive  rates,  the  rates  are  as  follows: 
Chimney-sweeps,  224.9;  seamen,  170.5;  brewers,  166.6;  tailors, 
112.9;  textile  manufacturers,  112.6;  fishermen,  111.9;  lawyers, 
1 1 1. 8;  inn-keepers,  108.8;  gas-works  service,  107.1;  corn-millers, 
105.3;  shoe-makers,  103.2;  butchers,  102.8;  malsters,  101.6; 
metal-workers,  101.1;  physicians,  101.1;  hatters,  101.0;  and 
glass- workers,  100.9.  These  occupations  are  not  typical  of  any 
one  pronounced  condition  of  employment  likely  to  be  considered 
a,  predisposing  cause  of  malignant  disease.  The  wide  variations 
in  occupational  conditions  suggest  that  the  causative  factors 
responsible  for  cancer  frequency  are  equally  varied  with  regard 
to  occupation  as  they  are  with  regard  to  age,  sex,  race,  etc.  The 
most  suggestive  result  of  this  analysis  is  the  unusually  high  mor- 
tality from  malignant  disease  in  three  specific,  though  widely 
different,  employments,  i.  e.,  chimney-sweeps,  seamen  and  brewers. 
It  is  equally  suggestive  that  relatively  high  cancer  death  rates 


10 


should  also  have  been  experienced  in  occupations  quite  similar 
thereto,  i.  e.,  fishermen,  malsters,  and  the  gas-works  service. 
The  direct  relation  between  occupation  and  malignant  disease 
is  largely  obscured  in  the  returns  for  industries  instead  of  for 
specific  occupations.  This,  however,  is  hardly  the  case  for  chimney- 
sweeps, seamen  and  brewers,  since  the  employees  in  these  groups 
follow  more  or  less  identical  pursuits,  or  are  more  or  less  exposed 
to  the  same  predisposing  occupational  conditions,  be  they  what  they 
may.  If  the  group  of  men  most  exposed  in  the  gas-works  service 
could  have  been  separated  from  the  men  not  so  exposed,  there 
is  a  practical  certainty  that  the  rate  for  this  occupation,  with 
exposure  more  or  less  similar  to  that  of  chimney-sweeps,  would 
have  been  materially  increased.  The  same  conclusion  applies 
to  fishermen,  who  represent  a  large  group  of  employees  with  widely 
varying  conditions  of  exposure,  chiefly,  of  course,  inland  or  shore 
fisheries,  as  different  or  distinct  from  fisheries  on  the  high  seas. 
If  the  latter  group  could  have  been  separately  considered,  it  is 
quite  possible  that  the  cancer  death  rate  would  have  been  materially 
increased  and  come  nearer  to  the  excessive  rate  found  to  prevail 
among  seamen. 

The  wide  variations  in  the  relative  distribution  of  the  organs 
and  parts  of  the  body  affected  by  cancerous  growths  in  different 
occupations,  are  best  brought  out  by  the  following  table  derived 
from  the  cancer  census  of  the  German  Empire  for  1902  : 

MORTALITY  PROM  CANCER  IN  THE  GERMAN  EMPIRE,  1902,  ACCORDING  TO 
OCCUPATIONAL  GROUPS,  AND  ORGANS  OR  PARTS  OF  THE  BODY  AFFECTED. 

Males. 


All  occupa-     Agricul- 
tions.  ture. 


Metal 
workers. 


Wood 
workers. 


Bones 

Skin 

Respiratory  organs. . 

Digestive  organs 

Urinary  organs 

Glands 

Breast 

Generative  organs . . . 


25 

21 

30 

41 

150 

250 

90 

no 

20 

7 

30 

21 

703 

642 

750 

685 

15 

8 

30 

13 

59 

54 

35 

96 

4 

i 

15 

13 

24 

17  • 

20 

21 

Total i,ooo 


1,000 


1,000 


II 


Females. 


All  occupa-      Agricul-         Textile       Domestic 
tions.  ture.  workers.        service. 


Skin  

73 

151 

52 

^u 

81 

Respiratory  organs  

3 

.  .  . 

5 

. 

Digestive  organs  

306 

338 

235 

323 

Urinary  organs  

6 

4 

10 

10 

Glands  

55 

73 

26 

61 

Breast  

243 

208 

287 

in 

Generative  organs  

303 

208 

375 

394 

Total i ,  ooo        i ,  ooo        i ,  ooo        i ,  ooo 

The  table  is  self-explanatory  and  requires  no  analysis,  but 
attention  may  be  directed  to  the  excessive  frequency  of  cancer 
of  the  skin  among  men  and  women  employed  in  agriculture, 
as  compared  with  other  occupational  groups.  The  cancer  occu- 
pation mortality  data,  derived  from  the  experience  (1907-1912) 
of  the  Prudential  Insurance  Company  of  America,  are  limited  to  a 
statement  of  the  male  deaths  in  specified  occupations  from  all 
causes  and  cancer  by  divisional  periods  of  life.  The  highest  pro- 
portionate mortality,  at  ages  35  and  over,  was  experienced  by  coal 
dealers,  or  12.3  per  cent.,  followed  by  teachers  with  11.3  per  cent., 
gardeners  with  8.5  per  cent.,  engineers  with  7.9  per  cent.,  tailors 
with  7.5  per  cent.,  brewers  with  5.7  per  cent.,  and  lawyers  with  5.0 
per  cent.  These  statistics,  to  a  limited  degree,  confirm  the 
English  experience  data,  and  also  the  occupational  cancer  statistics 
derived  from  other  sources. 

Statistical  information  must  always  be  of  secondary  value 
to  authentic  instances  of  cancerous  growth  directly  connected 
with  occupational  conditions.  In  the  vast  field  of  cancer  re- 
search cases  of  this  kind  must  aid  substantially  in  the  direction 
of  disclosing  the  true  nature  of  cancerous  processes,  particularly 
in  so  far  as  these  are  attributable  to  traumatism  or  long-continued 
irritation.  Typical  illustrations  of  cancers  resulting  from  specific 
injuries  more  or  less  connected  with  the  occupation  are  sufficiently 
numerous  to  preclude  the  possibility  of  mere  coincidence  in  cause 
and  effect.  Quite  a  number  of  typical  illustrations  of  traumatic 


12 

ulcers  and  cancers  are  to  be  found  in  Golebiewski's  "Atlas  and 
Epitome  of  Diseases  Caused  by  Accidents,"  including  cases  of 
carcinoma  of  the  kidneys,  liver,  peritoneum,  stomach,  spine  .and 
testicles.  In  detail  the  cases  cited  include  one  of  floating  kidney 
following  contusion  of  the  back  and  alleged  laceration  of  the 
kidney;  rupture  of  the  kidney  due  to  a  fall  from  a  scaffold;  car- 
cinoma of  the  stomach,  the  development  of  which  was  hastened 
by  an  accident  with  fatal  termination;  etc.  An  interesting  case 
of  cancer  of  the  stomach  following  a  single  and  short  overexertion 
in  connection  with  the  pushing  of  a  wheelbarrow,  has  recently 
been  reported  by  Dr.  Richard  Schornfeld,  of  Schonenberg.  (See 
Medical  Clinic,  Berlin,  May  17,  1914.) 

In  these  cases  the  relation  of  cancer  occurrence  to  traumatism 
was  apparently  well-established.  There  are  numerous  other 
instances  on  record  in  which  the  occurrence  of  malignant  growth 
is  more  indirectly  but  not  less  obviously  the  result  of  occupational 
conditions.  Some  of  these  have  been  summarized  in  an  admirable 
manner  by  Sir  Thomas  Oliver,  in  his  presidential  address  delivered 
in  the  Section  on  Industrial  Hygiene  at  the  Congress  of  the  Royal 
Institute  on  Public  Health  at  Paris,  on  May  16,  1913. 

As  early  as  1910  a  special  report  had  been  made  on  ulceration 
of  the  skin,  epitheliomatous  cancer,  in  the  manufacture  of  patent 
fuel  and  grease,  followed  by  a  further  report  and  draft  regulations 
in  1911,  and  a  final  report  by  Alfred  Herbert  Lush,  in  1913.* 
In  the  same  year  the  results  of  a  special  study  of  the  problem  of 
gas-works  and  pitch  industries  in  cancer  was  published  by  the 
John  Howard  McFadden  Researches,  in  which  the  assertion  oc- 
curs that  cancer  in  the  industries  referred  to  was  the  result  of 
chemical  agents,  known  as  augmentors,  in  the  chronically  injured 
site.  It  is  further  pointed  out,  in  explanation  of  this  important 
conclusion,  that  "there  must  be  two  factors  before  cancer  can 
supervene:  there  must  be  present  primarily  hi  the  injured  site 
the  auxetics  which  cause  benign  cell-proliferation  plus  augmentors 

1  The  recommendations  provided  (1)  for  suitable  bath  accommodations;  (2)  for  special 
protective  clothing;  (3)  for  the  encasing  of  disintegrating  machinery;  and  (4)  for  the  use  of 
wire  goggles  or  some  other  equivalent  protection  for  the  eyes.  Some  of  these  recommenda- 
tions, however,  were  subsequently  withdrawn  on  account  of  strenuous  objections  on  the 
part  of  employers  and  employees. 


13 

which  cause  malignant  cell-proliferation  when  mixed  with  auxetics. 
Hither  factor  by  itself  is  harmless — it  is  the  mixture  which  seems 
to  be  the  causative  agent." 

The  practical  importance  of  these  studies  is  in  connection  with 
the  administration  of  the  Workmen's  Compensation  Act  of  1906, 
which  includes  compensation  for  industrial  diseases.  In  the 
scheduled  diseases  directly  attributable  to  occupation  conditions 
for  which  compensation  is  required  to  be  paid  are : 

First,  eczoematous  ulceration  of  the  skin  produced  by  dust  or 
liquids,  or  ulceration  of  the  mucous  membrane  of  the  nose  or 
mouth  produced  by  dust.  Second,  epitheliomatous  cancer  or 
ulceration  of  the  skin,  or  of  the  corneal  surface  of  the  eye,  due 
to  pitch,  tar,  or  tarry  compounds.  Third,  serotal  epithelioma 
(chimney-sweeps'  cancer) . 

Epitheliomatous  cancer,  or  ulceration  of  the  skin,  or  of  the 
corneal  surface  of  the  eye,  due  to  pitch,  tar,  or  tarry  compounds, 
is  defined  by  Greer  in  his  treatise  oh  "Industrial  Diseases  and 
Accidents,"  as  follows: 

Continued  irritation  by  tar  and  its  congeners  may  produce  an  inflammation 
of  the  skin  (erythema),  and  this,  taken  with  the  blocking  of  the  ducts  of  the 
skin  glands  (tar  acne),  may  cause  the  skin  to  become  warty;  when  these 
warts  break  off  an  ulcer  is  often  found  underneath,  this  may  heal  up  or  it 
may  assume  a  malignant  character.  These  growths  occur  on  the  face,  hands 
and  scrotum  of  workers  engaged  in  the  handling  of  compounds  of  tar,  such  as 
making  briquettes  or  unloading  pitch,  etc.  These  substances  readily  penetrate 
the  working  clothes,  so  that  strict  cleanliness  is  a  useful  but  not  an  absolute 
preventive.  The  pitch  may  strike  the  eye  and  cause  an  ulcer,  which  may 
heal  up  leaving  a  scar  which  may  obstruct  the  vision,  or  the  ulcer  may  per- 
forate the  eye  and  destroy  it.  These  epitheliomatous  ulcers  are  dangerous, 
and  the  sooner  they  are  removed  by  operation  the  better. 

Sir  Thomas  Oliver  has  also  discussed  with  admirable  brevity 
the  essential  facts  regarding  malignant  vesical  growths  in  aniline 
workers,  it  being  stated  that  vesical  tumors  with  fatal  results 
were  thirty-three  times  more  frequently  observed  among  aniline 
dye  workers  than  among  the  general  male  population.  Sir 
Thomas  arrives  at  the  important  conclusion  that  the  cases  ob- 
served are  "an  illustration  of  the  occupation  being  a  cause  of 
malignant  disease,"  and  he,  therefore,  urges  the  need  of  protec- 
tive legislation  for  a  class  of  workers  engaged  in  an  indispensable 


14 

occupation.  The  occurrence  of  malignant  disease  in  the  manu- 
facture of  synthetic  dyes  has  been  reported  upon  with  exceptional 
thoroughness  by  Dr.  S.  G.  Leuenberger  of  the  Surgical  Clinic 
of  the  Pathological- Anatomical  Institute  of  Zurich,  in  1912.  The 
involved  nature  of  the  problem  is  best  emphasized  in  the  statement 
that  Dr.  Leuenberger's  monograph  has  appended  thereto  a  bibli- 
ography of  over  three  hundred  titles. 

Illustrations  of  the  specific  occupational  frequency  of  cancer, 
like  the  foregoing,  are  increasing  as  the  result  of  specialized  re- 
search and  more  careful  observations  on  the  part  of  the  general 
practitioner.  There  is  probably  no  more  promising  field  in  this 
respect  than  the  chemical  trade,  as  has  been  well  brought  out  in 
the  references  to  the  subject  by  Rambousek  in  his  treatise  on 
"Industrial  Poisoning,"  published  in  London,  1913.  Regarding  the 
occurrence  of  cancer  in  the  petroleum  industry,  this  writer  points 
out  that: 

The  occurrence  of  skin  affections  in  the  naphtha  industry  has  been  noted  by 
several  observers,  especially  among  those  employed  on  the  unpurified  mineral 
oils.  Eruptions  on  the  skin  from  pressing  out  the  paraffin  and  papillemata 
(warty  growths)  in  workers  cleaning  out  the  stills  are  referred  to  by  many 
writers. 

The  most  recent  study  of  paraffin  cancer,  or  of  coal  and  pe- 
troleum products  as  causes  of  chronic  irritation  and  cancer  is  by 
Dr.  Benjamin  Franklin  Davis,  of  Rush  Medical  College,  Chicago, 
reported  in  the  issue  of  the  Journal  of  the  American  Medical  As- 
sociation for  May  30,  1914.  The  results  of  this  investigation 
are  summed  up  in  the  conclusion  that:  "It  would  seem  safe  to 
assume  that  the  chronic-irritation  cancer,  produced  by  coal  and 
petroleum  products,  is  a  chemical-irritation  cancer,  and  that  it 
is  not  impossible  that  the  cancer  following  chronic  irritation  of 
other  origin  may  be  of  an  essentially  similar  nature." 

In  the  nation-wide  quest  for  cancer  knowledge,  there  would 
seem  to  be  few  efforts  more  certain  to  lead  to  practical 
results  than  the  strictly  scientific  study  of  the  occupational 
incidence  of  malignant  disease.  The  established  variation  in 
cancer  frequency  in  different  occupations  suggests  the  possibility 
that  the  causes  or  conditions  favorable  to  the  development  of 


15 

cancerous  growth  may  be  determined  with  greater  accuracy  on 
the  basis  of  occupational  observations  than  by  any  other  method 
or  means.  A  vast  amount  of  information  exists  which  has  not 
been  utilized  in  cancer  research.  The  analysis  of  occupational 
mortality  statistics,  with  special  reference  to  cancer,  is,  of  course, 
but  a  first  step  in  the  direction  of  strictly  scientific  research.  The 
work  of  Green,  of  Edinburgh,  established  the  apparently  close 
relation  between  sulphurous  acid,  or  sulpho-acid,  and  cancer 
frequency,  and  this  is  but  one  of  the  many  indications  of  useful 
results  following  cancer  inquiries  along  occupational  lines.  If 
there  were  no  other  evidence  available,  the  thoroughly  well- 
established  occurrence  of  cancer  following  X-ray  exposure  war- 
rants the  suggestion  that  a  much  larger  share  of  cancer  research 
work  should  be  devoted  to  the  relative  frequency  of  malignant 
disease  in  different  occupations  and  industries.  Just  as  on  the 
one  hand  cancer  is  known  to  be  exceptionally  common  in  certain 
employments,  so  on  the  other  hand  cancer  is  relatively  rare 
among  workmen  in  certain  other  employments,  among  which  men- 
tion may  be  made  of  tanners,  and  perhaps  coal  miners  also.  In  the 
experience  of  the  Bochum  Miners'  Union  for  1912,  out  of  2,490 
deaths,  only  91,  or  3.7  per  cent,  were  attributed  to  malignant 
disease.  The  experience  further  shows  that  out  of  242,645  ad- 
missions to  the  sick  fund  for  all  causes,  only  39,  or  0.02  per  cent, 
were  due  to  cancer.  In  the  English  experience  the  corrected 
cancer  death  rate  of  coal  miners  was  61.4  per  100,000  of  popula- 
tion, compared  with  265.5  for  chimney-sweeps  and  113.5  f°r  sea~ 
men.  It,  however,  has  been  shown  by  the  investigations  of 
Arnstein  that  malignant  disease  of  the  lungs  prevailed  to  a  re- 
markable extent  among  the  miners  of  the  Schneeberg  district  of 
Saxony.  The  minerals  mined  in  this  district  are  mostly  cobalt, 
bismuth  and  nickel.  According  to  Arnstein's  investigations, 
one-third  of  all  the  miners  admitted  to  the  local  hospitals  during 
the  period  1907-'!!  entered  with  a  diagnosis  of  cancer  of  the  lung 
and  this  was  given  as  the  cause  of  death  in  44  per  cent,  of  the  death 
certificates.  The  investigation  does  not  appear  to  have  been  made 
with  the  required  degree  of  careful  attention  to  precise  statistical 
analysis,  but  the  actual  cases  reported  in  full,  as  given  in  the 


16 

original  article  in  the  Vienna  Clinical  Weekly  for  May  8,  1913, 
fully  sustain  the  important  conclusions  of  the  author  and  suggest 
the  urgency  of  further  studies  in  this  promising  direction. 

The  established  occurrence  of  cancer  as  an  incidental  result 
of  the  manufacture  of  patent  fuel,  or  fuel  briquettes,  consisting 
of  coal-dust  and  pitch  in  the  usual  proportion  of  nine  to  one 
suggests  the  importance  of  a  careful  study  of  this  industry  in 
this  country,  since  the  same,  within  recent  years,  has  assumed 
considerable  proportions.  There  were  nineteen  plants  engaged 
in  the  manufacturing  of  fuel  briquetting  in  1912,  using  as  a  base 
anthracite  culm,  bituminous  or  semi-bituminous  slack,  carbon 
residue  from  gas  manufacture,  and  peat.  The  binders  used  varied 
also  and  of  the  nineteen  plants  in  commercial  operation  during 
1912  coal-tar  pitch  was  used  as  a  binder  by  ten,  one  used  asphaltic 
pitch,  two  used  water-gas  pitch,  and  four  used  mixed  binders, 
the  composition  of  which  was  not  made  public.  There  are 
few  recorded  cases  of  so-called  pitch  cancer  in  this  country, 
but  it  is  quite  possible  that  increasing  attention  and  more  careful 
observation  may  prove  that  ulcerations  of  the  skin,  as  well  as 
true  cancer,  occur  in  this  country,  as  well  as  in  England  and 
Wales,  in  connection  with  the  manufacture  of  patent  fuel,  etc. 
It  should  be  stated,  however,  in  this  connection  that  a  case  of 
multiple  cancer  of  the  skin  in  a  tar- worker,  who  developed  several 
scores  of  epithelial  lesions  in  various  stages  of  development  upon 
the  hands  and  forearms  and  a  large  epithelioma  upon  the  scrotum, 
has  been  reported  by  Dr.  J.  Frank  Schamberg,  of  Philadelphia. 
The  case  suggested  to  Dr.  Schamberg  the  possibility  of  radio- 
activity in  coal-tar  and  to  test  this  assumption,  according  to  the 
Medical  Record,  he  "placed  a  copper  cent,  a  flat  key  and  a  small 
brass  numeral  upon  a  photographic  plate  in  a  pasteboard  negative 
box  lined  with  black  paper.  Upon  the  under  surface  of  the  lid 
he  attached  a  piece  of  cardboard  smeared  with  coal-tar,  so  that 
the  board  faced  downward.  This  box  was  placed  in  a  black 
Japan  tin  cash  box  and  the  latter  was  shut  in  a  dark  closet  for 
twenty-four  hours.  When  the  plate  was  developed  a  distinct 
shadowgraph  of  the  three  objects  was  seen  on  the  negative." 
This  test  of  coal-tar  radioactivity  is  conceded  by  Dr.  Schamberg 


to  be  hardly  conclusive,  but  he  observes  that  "If  coal-tar  was 
proven  to  be  radioactive,  it  would  seem  that  this  radioactivity 
might  be  responsible  for  the  cancer  in  tar- workers."  According 
to  another  account,  Dr.  Schamberg  examined  about  twenty 
men  whose  work  caused  them  to  be  smeared  with  tar.  In  the 
manufacture  of  tar-paper  the  men's  arms  are  soiled  with  tar  and 
their  clothing  is  more  or  less  saturated.  Most  of  the  men  said 
that  they  suffered  from  time  to  time  with  outbreaks  of  "yellow- 
heads"  on  their  arms,  but  these  soon  passed  away.  In  a  number 
of  workmen  he  saw  mild  acneform  eruptions  on  the  arms  resembling 
a  folliculitis.  Five  workmen  were  found  showing  evidences  of 
beginning  or  well-developed  cancer. 

The  study  of  radioactive  substances  in  their  relation  to  cancer 
and  occupation  offers  a  field  of  considerable  promise.  The  ad- 
mirable experimental  inquiry  by  Lazarus-Barlow  suggests  re- 
sults of  considerable  practical  value.  With  regard  to  substances 
commonly  supposed  to  be  causally  related  to  carcinoma,  this 
author  states  that: 

Numerous  samples  of  clay  pipe,  soot,  pitch,  paraffin  wax,  metallic  arsenic, 
arsenious  oxide,  betel  nut,  cholesterin  gallstones,  pigment  gallstones,  renal 
and  vesical  calculi,  have  been  examined  skotographically,  the  calculi,  renal, 
biliary,  and  vesical  being  made  the  subject  of  an  extended  research  by  Dr. 
Col  well.  Skotographic  effect  was  exhibited  by  one  sample  of  soot  out  of  two 
examined,  by  betel  nut  on  all  of  numerous  occasions,  by  each  of  twenty-three 
specimens  of  cholesterin  gallstone,  more  or  less  "pure,"  in  three  out  of  four 
samples  of  pigment  gallstones  examined,  the  effect  being  always  very  slight 
as  compared  with  the  action  of  the  cholesterin  calculi,  and  by  thirty  out  of 
thirty-eight  vesical  calculi.  Metallic  arsenic  and  arsenious  oxide  produced 
effects  upon  the  photographic  plates,  but  inasmuch  as  the  films  showed 
alteration  before  development  the  action  cannot  be  regarded  as  skotographic. 
On  the  other  hand,  none  of  nine  specimens  of  clay  pipe,  of  numerous  samples 
of  paraffin  wax,  of  four  samples  of  pitch  from  different  localities,  of  several 
specimens  of  coal,  yielded  the  slightest  trace  of  skotographic  action.1 

Even  though  the  evidence  was  rather  negative,  it  would  seem 
well  worth  while  to  carry  on  further  experimental  research  along 
the  lines  suggested. 

The  relatively  high  frequency  of  cancer  among  seamen  and 
fishermen  would  seem  to  support  the  theory  advanced  by  Wilfred 

i  See  British  Medical  Journal,  June  19,  1909. 


i8 

Watkins  Pitchford,  M.D.,  Government  Pathologist  of  Natal, 
in  an  address  on  "Light  Pigmentation  and  New  Growth,"  in 
which  the  view  is  advanced  that,  "The  increase  of  cancer  within 
the  last  seventy-five  years  is,  perhaps,  due  to  the  diminished 
protection  from  light  and  increased  exposure  to  illumination. 
Woolen  garments  have  been  largely  replaced  by  cotton,  and  black 
and  brown  clothes  by  those  of  a  light  color.  Narrow  streets 
and  dark  houses  are  no  longer  tolerated  and  suburban  life  has 
largely  replaced  tint  of  the  city.  Artificial  light  has  become  more 
actinic  in  its  character."  He  further  concludes,  as  a  manifest 
deduction  from  the  foregoing  principles,  that  cancer  may  be 
prevented  by  efficient  protection  of  the  body  from  light  and  that 
natural  protection,  such  as  hair  upon  the  face,  should  be  encour- 
aged. The  clothing  should  be  absolutely  light-proof.  The 
ventral  surface  of  the  throat  and  abdomen  should  be  especially 
protected.  Considering  the  almost  universal  non-protection  of  the 
upper  portion  of  the  chest  of  women  at  the  present  time,  the  con- 
clusion of  this  author  may  be  quoted  as  a  word  of  warning,  to 
the  effect  that,  "Mammary  cancer  in  women  is  usually  due  to 
insufficient  protection  of  the  breast  from  light."  This  ingenious 
author,  it  may  be  said  by  inference,  also  advances  an  explanation, 
at  least  in  part,  why  the  native  or  dark-skinned  races,  should 
apparently  be  so  much  less  liable  to  malignant  disease  than  the 
white  races  living  in  tropical  or  non- tropical  countries.  The  very 
complex  and  involved  theory  which  underlies  the  practical  ap- 
plication of  the  principles  of  actinic  therapy  cannot  be  discussed 
in  detail.  The  X-ray,  radium,  thorium,  etc.,  are  not  only 
applied  for  purposes  of  treatment  in  cancer,  but  certainly  in  the 
case  of  X-rays,  a  distinct  form  of  malignant  dermatitis  is  of  rela- 
tively common  occurrence  among  workers  exposed  to  X-ray  emana- 
tion. An  extended  account  of  the  surgical  treatment  of  X-ray  car- 
cinoma by  Dr.  C.  A.  Porter,  of  the  Harvard  Medical  School, 
published  in  the  "Fifth  Report  of  the  Cancer  Commission  of  Har- 
vard University,"  includes  eleven  cases  of  undoubted  X-ray  can- 
cers, of  which  six  proved  fatal.  A  remarkable  fact  disclosed  by 
this  investigation  and  not  generally  recognized  as  rather  in  con- 
trast to  general  experience,  was  the  fact  that  prolonged  action 


19 

of  the  X-ray  upon  previously  healthy  skin  resulted  in  malignant 
growth  in  persons  who  were,  almost  without  exception,  of  an  age 
which,  broadly  speaking,  is  not  the  cancer  period  of  life.  I  quote 
from  this  very  interesting  and  important  discussion  the  following 
suggestive  conclusion: 

Though  the  harmful  results  of  continuous  exposure  to  the  X-rays  were 
unknown  to  the  early  workers  in  this  field,  it  would  seem  that  unwittingly 
they  have  given  us  the  best  demonstration  yet  known  of  the  artificial  or 
experimental  production  of  cancer.  It  is  unlikely  that  old  age  itself,  with 
its  accompanying  skin  atrophies,  even  if  combined  with  exposure  to  such 
various  noxious  influences  as  sea  life,  raw  winds,  powerful  actinic  rays,  soot 
or  paraffin,  would  give  such  an  example  of  malignant  skin  degeneration  as 
seems  so  frequently  to  result  from  protracted  exposure  to  the  X-ray.  When 
it  is  remembered  that  these  lesions  have  been  produced  in  young  men  at  an 
age  when  skin  cancer  is  extremely  rare,  its  occurrence  is  all  the  more  strik- 
ing. 

An  ingenious  explanation  has  been  advanced  by  Green,  of  Edin- 
burgh, in  his  discussion  of  the  cancer  problem,  in  which,  after  stating 
that  X-rays  admittedly  caused  a  dormatitic  and  thereby  diminished 
the  resistance  of  the  epithelium,  he  said  that  it  must  not  be  for- 
gotten that  most  X-ray  operators  have  also  to  prepare  many 
skiagraphs  and  develop  the  negatives.  This,  in  his  opinion, 
is  the  direct  cause  of  X-ray  dermatitis,  or  in  his  own  words, 
"fixing  of  plates  by  means  of  hyposulphite  with  fingers,  the  skin 
resistance  of  which  is  already  weakened,  is  much  more  likely  to 
cause  the  epithelioma  than  the  rays  themselves." 

The  foregoing  discussion  of  an  important  phase  of  the  cancer 
problem  suggests  the  urgency  of  more  extended  occupational 
studies  than  have  thus  far  been  made.  The  cumulative  evidence 
would  tend  to  establish  the  truth  or  the  falsity  of  prevailing  opinion 
and,  in  any  event,  eliminate  much  needless  and  even  misleading 
information.  The  fundamental  principle  of  irritability  as  the 
direct  cause  of  cancerous  growth  is  apparently  well  sustained  by 
occupational  studies  of  the  cancer  problem.  All  disease,  it  is 
held  by  the  foremost  author  on  irritability,  or  the  effect  of  stimuli 
on  living  substances,  "consists  of  the  influence  of  stimuli  upon 
these  physiologic  processes."  Every  disease,  according  to  this 
author,  "represents  only  a  disturbance  of  the  physiologic  pro- 


20 

s\ 

cesses  of  cell  life  of  the  organism  and  the  harmony  in  their  com- 
bined workings."  Believing  that  the  available  evidence  regarding 
cancer  warrants  the  conclusion  that  malignant  disease  is  not  the 
result  of  a  single  cause,  I  cannot  do  better  than  conclude  by  quoting 
the  following  most  carefully  considered  remarks  of  Dr.  Max 
Verworn,  the  author  of  the  treatise  on  irritability : 

Another  point  concerning  the  application  of  the  conception  of  cause  seems 
to  me,  however,  to  be  of  much  more  importance,  namely,  that  a  single  cause 
is  held  responsible  for  the  taking  place  of  a  process.  One  endeavors  to  ex- 
plain a  process  in  general  by  seeking  for  its  "cause."  The  cause  being  found, 
the  process  is  considered  as  fully  accounted  for.  This  idea  is  not  one  widely 
spread  in  every-day  life,  but  is  even  found  frequently  in  natural  science, 
especially  in  biology,  although  here,  it  should  be  known,  the  processes  are 
decidedly  more  complicated.  The  search  for  the  "cause"  of  development, 
for  the  "cause"  of  heredity,  for  the  "cause"  of  death,  for  the  "cause"  of  the 
respiration,  for  the  "cause"  of  the  heart  beat,  for  the  "cause"  of  sleep,  for 
the  "cause"  of  disease,  etc.,  was  for  a  long  time  and  frequently  even  today 
a  characteristic  of  biologic  investigation.  As  if  such  a  complicated  process 
as  development,  death  or  disease  could  be  explained  by  a  single  factor:  In 
reality,  one  has  obtained  very  little  as  a  result  of  the  analysis  of  a  process  by 
discovering  its  cause ;  and  in  addition  the  false  impression  arises  that  through 
the  finding  of  this  one  factor  the  process  has  been  definitely  explained.  It 
has  been  generally  recognized  in  the  natural  sciences  in  recent  times  that  no 
process  in  the  world  is  dependent  upon  one  single  factor  and  attempts  have 
been  made  to  give  this  fact  more  consideration. 

The  foregoing  conclusions  apply  with  special  force  to  the  cancer 
problem  and  provide  the  best  possible  answer  at  the  present  time 
to  the  constantly  recurring  question  as  to  the  primary  cause  of 
cancer  and  its  direct  relation  to  the  larger  problems  of  prevention, 
treatment  and  control. 


II. 

THE  ECONOMIC  IMPORTANCE  OF  LEAD  POISONING.1 

By  ALICE   HAMILTON,   M.A.,   M.D.,   Hull-House,   Chicago. 

Layet  estimated  that  in  France  there  are  one  hundred  and  twenty 
industrial  processes  which  involve  the  use  of  lead  or  lead  com- 
pounds. The  Occupational  Diseases  Commission  of  Illinois 
found  that  lead  poisoning  had  actually  occurred  in  that  state  in 
connection  with  about  seventy  different  occupations  during  three 
years'  time,  and  the  New  York  State  Factory  Investigating 
Commission  has  added  several  trades  to  the  Illinois  list.  No 
poisonous  substance  finds  nearly  as  great  use  in  manufacturing 
processes  as  does  lead  and  that  is  why  the  Germans  call  plumbism 
the  occupational  poisoning  par  excellence. 

It  is  quite  impossible  to  form  even  an  estimate  of  the  persons 
who  are  exposed  to  lead  in  our  industries.  In  the  trades  studied 
by  the  Bureau  of  Labor  there  are  a  few  where  the  number  em- 
ployed is  fairly  well  known.  The  making  of  red  lead  employed 
in  1911  about  300  men  east  of  the  Pacific  coast;  the  20  principal 
smelters  and  refineries  employ  7500,  all  of  them,  as  of  the  red 
lead  workers,  exposed  to  lead.  Much  more  numerous  than  any 
other  class  of  lead  workers  are  the  painters  but  how  many  of  them 
come  in  contact  with  lead  no  one  knows,  for  in  the  census  they 
are  classed  together  with  varnishers  and  glaziers  and  not  all 
painters  handle  lead  paint.  Still  they  are  numerically  the  most 
important  of  the  lead  workers. 

The  glazing  of  toilet  ware  and  sanitary  ware  in  Trenton  and  in 
the  East  Liverpool  district  requires  the  work  of  about  800  men  and 
150  women.  In  the  art  and  utility  potteries  (majolica  ware) 
of  the  Zanesville  (Ohio)  district  and  in  the  principal  tile  works 
in  the  country  there  are  about  300  men  and  250  women  engaged 
in  making,  and  applying  lead  glaze  and  in  decorating  with  lead 
colors.  The  ten  largest  plants  manufacturing  porcelain  enamelled 

1  This  paper  is  based  on  investigations  made  for  the  Bureau  of  Labor  Statistics  of  the 
following  lead  trades:  smelting  and  refining  lead;  making  white  lead,  red  lead,  storage 
batteries;  glazing  and  decorating  pottery  and  tiles;  enamelling  sanitary  iron  ware;  painting. 
Bulletins  95,  104,  120,  140,  142. 


22 

bath  tubs  and  sinks  employ  something  over  a  thousand  men  in 
making  and  handling  the  enamel. 

The  making  of  white  lead  is  one  of  the  most  dangerous  of  lead 
industries.  In  the  23  establishments  east  of  the  Pacific  coast 
which  were  making  white  lead  in  191 1,  there  were  1600  men  needed 
to  keep  up  the  monthly  pay-roll.  Another  unusually  dangerous 
lead  industry  is  the  making  of  storage  batteries  and  the  five 
largest  plants  in  the  United  States  employ,  all  told,  something 
less  than  950  men  in  the  processes  involving  exposure  to  lead. 

These  figures  added  together  would  not  give  a  total  of  the  men 
and  women  who  in  the  course  of  a  year  would  run  the  risk  of  lead 
poisoning  in  these  trades.  As  a  matter  of  fact  the  number  would 
be  more  than  double  that,  for  the  only  trades  in  this  list  which 
employ  a  steady  force  of  workmen  are  the  organized  branch  of 
the  pottery  industry  and  the  organized  branch  of  the  painters. 
In  all  the  others  there  is  a  stream  of  workers  moving  in  and  out 
all  the  time,  so  that  in  a  smelter,  or  a  refinery,  or  a  white  lead 
plant,  or  a  storage  battery  plant,  it  may  be  necessary  to  hire  in 
the  course  of  a  month  from  20  to  50  per  cent,  of  new  men.  In 
one  refinery  on  the  Atlantic  coast  less  than  30  per  cent,  of  the  men 
had  stayed  as  long  as  a  year,  in  a  white  lead  plant  with  a  regular 
pay-roll  of  58  there  were  250  men  on  the  books  in  six  months' 
time,  and  a  storage  battery  plant  was  found  which  had  recently 
changed  practically  the  whole  of  the  pasting  force  so  that  where 
there  had  been  exclusively  Russian  Jews  there  were  only  Slavs 
to  be  found. 

When  we  consider  that  the  industries  mentioned  are  only  a 
few  of  those  using  lead  and  that  some  of  the  others  also  are  large 
and  give  employment  to  a  changing,  shifting  mass  of  men,  it  be- 
comes evident  that  in  the  course  of  a  year  a  very  great  number  of 
workmen  are  exposed  to  lead  poisoning  in  our  industries.  In 
some  of  the  lead  trades  poisoning  usually  takes  place  slowly  and 
a  man  may  work  along  for  months  or  even  years  without  experi- 
encing trouble.  Printers,  painters  who  do  exterior  work,  sign 
painters,  and  glost  kilnmen  in  the  potteries,  do  not  have  acute 
plumbism  unless  they  belong  to  the  unusually  susceptible.  On 
the  other  hand  the  period  of  exposure  to  lead  is  short  in  the  majority 


23 

of  cases  which  develop  in  the  white  and  the  red  lead  industries, 
in  enamelling  bath  tubs,  in  smelting,  in  making  storage  batteries 
and  in  glazing  tiles.  Thus  in  the  first  of  these  trades  only  31 
out  of  120  men  with  lead  poisoning  had  worked  as  long  as  a  year 
before  becoming  sick,  8  had  sickened  in  less  than  two  weeks' 
time  and  39  in  less  than  a  year.  Thirty-four  mixers  of  enamel 
averaged  a  little  over  6  months'  employment.  The  cases  which 
developed  among  smelters  had  usually  come  on  after  less  than 
four  months'  exposure  and  of  60  storage  battery  makers  only 
two  had  worked  a  year  and  50  less  than  six  months.  This  shows 
that  it  is  little  protection  to  the  men  to  have  them  shift  often, 
indeed,  the  result  is  to  bring  in  continually  fresh  victims,  for  among 
the  new  men  will  always  be  a  proportion  of  the  oversusceptible, 
and  with  such  a  shifting  force  it  is  impossible  to  eliminate  them 
and  settle  down  to  tried  and  seasoned  workmen.  Legge  finds 
a  much  larger  proportion  of  plumbism  among  the  casual  workers 
in  the  white  lead  industry  in  England  than  among  those  steadily 
employed,  the  figures  being  39  per  cent,  for  the  former  and  only 
6  per  cent,  for  the  latter. 

The  actual  number  of  cases  of  occupational  lead  poisoning 
in  any  trade  is,  under  our  American  methods,  impossible  to  dis- 
cover. To  be  sure  many  of  the  states  now  have  laws  for  the 
reporting  and  registration  of  all  such  cases,  but  these  are  too 
recent  for  us  to  know  what  success  we  shall  attain  by  them. 
In  Illinois  the  law  applies  only  to  physicians  who  are  officially 
connected  with  lead  industries.  Our  sick  benefit  associations 
have  no  records  that  are  of  any  value  except  in  a  few  minor 
instances.  Therefore,  the  figures  contained  in  the  Government 
reports  concerning  occupational  plumbism  in  certain  trades  are 
all  merely  approximate;  it  has  never  been  possible  to  discover 
all  the  cases  since  the  only  available  sources  of  information  are 
the  records  of  hospitals  and  of  physicians  and  the  statements  of 
the  men  themselves. 

Even  with  these  drawbacks  the  rate  of  lead  poisoning  dis- 
closed in  the  industries  so  far  studied  is  very  large.  Among 
the  7500  men  in  our  smelters  and  refineries  no  less  than  1769 
cases  were  discovered  during  1912,  a  rate  of  23  per  hundred.  The 


24 

makers  of  white  and  red  lead,  some  1600,  had  388  cases  in  16 
months  time,  or  a  rate  of  18  per  cent,  in  a  year.  930  storage 
battery  makers  had  a  rate  of  17.4  per  cent,  during  1913.  The 
noo  pottery  workers  had  8  per  cent,  for  the  men  and  14  per  cent, 
for  the  women,  rates  which  were  almost  exactly  double  those  for 
the  men  and  women  in  the  British  potteries.  Enamellers  of  bath 
tubs  and  sinks  suffer  more  than  potters.  In  the  10  plants  em- 
ploying something  less  than  noo  men  there  were,  in  1911,  217 
cases  of  poisoning,  a  rate  of  21  per  cent.,  but  an  intensive  study 
of  148  men  brought  to  light  a  much  larger  proportion,  for  54, 
or  36  per  cent.,  of  them  showed  signs  of  chronic  plumbism. 

The  painters'  trade  is  always  the  hardest  of  the  lead  trades  to 
study  and  in  our  country  with  our  lack  of  sickness  insurance, 
it  is  impossible  to  find  out  how  many  painters  suffer  from  plumbism. 
A  local  union  sent  out  to  its  members,  chiefly  house  painters, 
a  questionnaire  which  was  answered  by  1009  men.  185  of  them 
gave  a  history  of  plumbism,  72  of  kidney  trouble,  27  of  chronic 
digestive  disturbance  and  77  of  rheumatism.  100  house  painters, 
not  disabled  by  sickness,  consented  to  submit  to  a  thorough 
physical  examination  to  determine  the  signs  and  symptoms  of 
plumbism.  It  was  carried  out  by  Dr.  E.  R.  Hayhurst,  of  the 
Occupational  Disease  Clinic,  Rush  Medical  College,  Chicago, 
who  in  addition  to  the  physical  examination,  made  estimations 
of  the  blood  pressure,  and  examined  blood  and  urine.  To  sum- 
marize his  finding:  symptoms  of  acute  lead  poisoning  were  not 
found  in  any  case,  but  indications  of  chronic  plumbism  were 
found  in  at  least  59  cases. 

Just  how  much  disability  and  economic  loss  this  means,  loss 
of  wages  during  illness  and  of  earning  capacity  after  recovery, 
it  is  hard  to  say.  Acute  lead  poisoning  usually  seems  to  mean  a 
sojourn  of  five  to  fifteen  days  in  a  hospital,  after  which  the  patient 
is  discharged  "recovered."  This  recovery  does  not  always  mean 
that  the  man  is  well  enough  to  go  back  to  work.  Even  in  mild 
cases  it  is  often  a  month  before  he  has  recovered  his  full  strength, 
and  many  cases  are  not  mild.  The  British  factory  inspection 
service  classifies  all  cases  of  lead  poisoning  as  follows:  Slight, 
including  (i)  colic  without  complications  and  of  comparatively 


25 

short  duration,  (2)  anemia  in  adolescence  aggravated  by  employ- 
ment, (3)  either  of  the  above  with  tendency  to  weakness  of  the 
extensors;  moderate,  (i)  colic  with  anemia,  (2)  profound  anemia, 
(3)  partial  paralysis,  (4)  constitutional  debility;  severe,  (i)  marked 
paralysis,  (2)  encephalopathic  conditions,  (3)  grave  undermining 
of  the  constitution  associated  with  paralysis,  renal  disease,  or 
arterio-sclerosis.  If  we  adopt  the  same  system  for  American 
cases  we  find  in  the  potteries: 

Males.  Females. 

Per  cent.  Per  cent. 

Slight 48.3  60.8 

Moderate 45  .3  27 .5 

Severe 8.1  n.8 

In  the  work  of  enamelling,  the  form  of  poisoning  is  likely  to 
be  more  serious.  Here  the  proportion  of  slight  cases  was  only 
40  per  cent,  of  moderate,  48.1  per  cent,  and  of  severe,  11.9  per 
cent.  There  were  28  men  with  pronounced  palsy  and  8  with 
encephalopathy. 

In  one  lead  smelter  there  were,  during  1912,  81  cases  of  which 
56  were  slight,  17  moderate  and  8  severe.  But  it  is  among  painters 
who  remain  long  in  their  trade  that  one  finds  the  largest  propor- 
tion of  serious  plumbism.  A  study  of  100  lead-poisoned  painters 
showed  that  only  33  had  had  simple  lead  colic  without  compli- 
cations, 42  had  had  palsy,  9  encephalopathic  conditions,  n  eye 
disturbances  and  n  arterio-sclerosis.  The  average  of  employ- 
ment at  the  trade  was  15.77  years. 

The  pasters  in  a  storage  battery  factory  usually  suffer  from 
rapidly  developing  and  uncomplicated  lead  poisoning,  yet  if 
these  men  are  followed  up  it  will  be  seen  that,  simple  and  acute 
as  the  disease  is,  the  effects  are  sometimes  slow  to  clear  up.  For 
instance  this  is  the  record  of  twelve  such  cases  who  were  looked 
up  within  a  year  of  their  illness. 

Length  of  time  employed.  Incapacitated. 

8  months 3  weeks 

3  months 3  weeks 

6  months .' 4  weeks 

5  months 5  weeks 

2l/2  months 5  weeks 


26 
Length  of  time  employed.  Incapacitated. 

3  months 2  months 

5  weeks 2  months 

5  months 3  months 

21/*  months 3  months 

6  weeks 3  months 

6  months 4  months 

6  months 4  months 

This  is  only  the  general  run  of  cases.  Were  one  to  pick  out 
the  unusual  cases  one  could  produce  a  tragic  picture  of  early 
breakdown,  of  men  in  the  prime  of  life  with  advanced  arterio- 
sclerosis, of  skilled  workmen  forced,  because  of  palsy,  to  become 
night  watchmen  or  care  takers  of  lavatories,  of  nervous  breakdown, 
mental  deterioration,  insanity,  even  death.  Every  one  of  the 
trades  thus  far  studied  has  yielded  numbers  of  such  cases. 

Tuberculosis  is  the  great  foe  of  the  working  classes,  but  next  to 
tuberculosis  comes  lead  poisoning  and  according  to  our  present 
knowledge  the  two  go  hand  in  hand,  for  lead  favors  the  develop- 
ment of  tuberculosis  by  lowering  the  resistance  of  the  body  to 
infection. 


III. 

HYGIENE  AND  MACHINERY  HAZARDS. 

By  C.  T.  GRAHAM-ROGERS,  M.D.,  Director,  Division  of  Industrial  Hygiene,  Department 
of  Labor  of  the  State  of  New  York,  New  York  City. 

"Safety  first"  has  been  the  slogan  in  the  industrial  field.  Safety 
organizations  have  been  instituted  and  the  profession  of  safety 
engineering  has  been  established;  strangely  coincident  with  the 
enactment  of  drastic  factory  laws  and  workmen's  compensation 
acts. 

Safety  engineering  is  concerned  with  the  machinery  hazards 
purely  from  the  financial  standpoint  of  the  employer.  We  also  have 
the  insurance  inspector,  who  is  concerned  with  the  hazard  as  a 
question  of  reduction  of  the  company's  liability.  Finally,  we 
have  the  factory  inspector,  who  is  concerned  with  the  conservation 
of  the  health  of  the  individual,  the  direct  outcome  of  which  has 
been  the  medical  inspection  of  factories. 

As  a  result  of  the  medical  inspection  of  factories  in  the  State  of 
New  York,  it  has  been  proved  that  accident  prevention  where 
there  is  machinery  hazard  is  a  distinct  branch  of  industrial  hy- 
giene, with  the  result  that  there  has  been  created  in  connection 
with  the  New  York  State  Labor  Department  a  division  of  In- 
dustrial Hygiene,  composed  of  engineers,  chemists,  physicians, 
working  in  harmony,  so  that  the  definite  cause  may  be  determined 
and  specific  preventive  measures  applied. 

The  cause  of  accidents  on  or  about  machinery,  as  well  as  the 
safeguard  to  be  applied  to  prevent  such  accidents,  should  not  be 
considered  from  a  mechanical  standpoint  alone,  as  is  the  usual  case. 
The  human  element,  as  well  as  the  conditions  under  which  the 
work  is  being  performed,  is  of  great  importance,  and  as  a  rule 
entirely  neglected.  There  should  also  be  studied  the  ultimate 
effects  upon  the  workers  due  to  the  attachment  of  preventive 
measures  to  the  machine,  for  it  avails  but  little  if  so-called  "fool- 
proof" safety  measures  be  applied,  and  yet  the  operator's  health 
be  impaired  thereby. 

Considering   machinery   hazard   from   a   hygienic   standpoint, 


28 

accident  may  be  due  to  the  questions  of  lighting,  air  condition- 
ing, cleanliness,  fatigue  and  personal  hygiene. 

Improper  lighting  is  an  inexcusable  sanitary  defect,  and  is  a 
factor  in  the  cause  of  many  accidents.  Poor  lighting  about 
machinery,  especially  stamping  machinery,  or  where  there  are 
gearing,  pulleys  or  belts,  is  the  cause  of  accident  through  the 
inability  of  the  person  to  distinguish  objects  clearly.  Glaring 
light  is  also  an  important  factor. 

Air  conditioning  is  of  importance,  for  no  worker  can  be  em- 
ployed in  a  high  or  low  temperature,  or  relative  humidity,  not 
properly  proportionate  to  the  temperature,  without  lowering  the 
vital  resistance  of  the  body.  Where  such  workers  are  employed 
about  machinery,  they  become  less  alert,  and  more  liable  to  in- 
jury. It  has  been  shown  where  accidents  occur  quite  frequently 
that  the  number  has  been  diminished  after  the  installation  of 
proper  ventilation. 

Where  machines  are  subjected  to  corrosion  through  acids  or 
fumes,  there  is  considerable  hazard,  unless  these  fumes  are  efficiently 
removed  through  proper  and  sufficient  means  of  ventilation. 

Cleanliness  is  of  importance ;  if  rubbish  is  permitted  to  accumu- 
late, it  at  times  interferes  with  the  proper  working  of  machinery, 
and  the  operators  are  made  to  remove  such  rubbish  while  the 
machines  are  in  motion,  whereas  constant  cleanliness  should 
practically  reduce  the  hazard. 

In  certain  industries,  large  quantities  of  dust  are  generated; 
this  not  only  accumulates  about  the  machine,  but  by  being 
inhaled,  causes  pulmonary  affections;  also,  by  irritating  the  eyes 
of  the  operator  increases  the  danger.  For  example,  I  might  cite 
first,  the  case  of  circular  saws;  considerable  dust  is  generated 
here,  and  unless  properly  removed,  the  operator  is  unable  to  see 
his  work  clearly,  and,  despite  the  fact  that  certain  types  of  guards- 
may  be  attached  to  the  machine,  the  result  is  disastrous  to  him- 
self. In  this  case  an  exhaust  system  is  necessary  in  addition  to 
the  guard.  Another  case  may  be  cited,  that  of  guarding  a  shaper, 
which  is  a  rapidly  revolving  spindle  with  sharp  knives,  and  a 
machine  to  which  it  is  at  times  difficult  to  apply  a  safeguard.  In 
the  course  of  operation,  large  quantities  of  shavings  and  dust 


29 

are  created,  and  it  becomes  necessary  for  the  operators  to  remove 
this  accumulation;  automatically,  they  move  their  hands  to  push 
away  the  shavings  or  try  to  blow  them  away.  Very  often,  serious 
accidents  occur  through  the  fingers  coming  in  contact  with  the 
sharp  knives,  a  result  of  this  almost  uncontrollable  rhythmic 
motion.  Here,  again,  is  the  question  of  the  removal  of  dust; 
this  can  be  done  only  by  the  means  of  an  air  jet.  A  combination 
•of  improper  lighting  and  impure  air  conditioning  often  results 
in  accidents  on  looms  and  on  automatic  steel  stamping  machines. 
This  condition  was  described  by  me  some  years  ago,  in  a  paper, 
and  for  which  I  used  the  term  "mechanical  hypnotism."  In 
these  cases,  the  worker  is  subjected  to  the  glare  of  the  light  and 
to  lowered  vital  resistance,  due  to  vitiated  air.  Influenced 
by  the  constant  monotonous  din  of  the  machinery,  the  worker 
becomes  practically  a  part  of  the  rhythm;  something  happens 
to  break  this  rhythm,  and  before  the  operator  can  recover  the 
natural  poise,  an  accident  has  happened. 

Personal  hygiene  is  also  an  important  factor  in  machine  hazards, 
especially  where  women  are  employed.  Constant  friction  of 
belts  on  pulleys  generates  electricity,  and  where  women  or  girls 
are  working  close  to  such  belting,  the  strands  of  the  hair  are  at- 
tracted and  become  entangled  in  the  lacing  or  pulley.  Protec- 
tion in  this  case  is  proper  head  covering.  The  absence  of  proper 
over-clothing,  such  as  overalls  for  men,  or  aprons  for  females, 
is  a  factor,  as  torn  clothing  or  loose  sleeves  might  catch  in  ex- 
posed portions  of  machinery  with  fatal  results. 

The  application  of  guards  should  not  be  considered  merely 
a  point  of  accident  prevention.  Very  little  is  accomplished  if 
the  guard  is  placed  about  the  machine  to  reduce  the  hazard,  and 
the  operator's  sight  is  ultimately  affected,  or  an  occupational 
neurosis  results. 

For  example:  on  stamping  machines,  where  it  is  essential  that 
there  be  proper  safeguards  to  prevent  the  workers'  hands  and 
fingers  being  caught  between  the  die  and  anvil,  there  is  danger 
to  the  health  of  the  operator,  if  the  type  of  guard  consisting  of  a 
rapidly  moving  wire  mesh  is  used;  for  in  this  case  where  the 
loss  of  limb  is  prevented,  the  loss  of  eyesight  is  being  encouraged. 


30 

Another  example  is  on  machinery  where  it  is  endeavored  to 
place  a  guard  requiring  the  movement  of  both  hands  in  order 
to  trip  the  machine;  here  again  the  loss  of  limb  is  prevented,  but 
the  loss  of  vital  resistance  is  encouraged  by  requiring  a  constant 
monotonous  movement.  This  is  akin  to  the  very  speeding  up, 
of  which  we  hear  so  much,  and  which  we  are  endeavoring  to  pre- 
vent. 

These  are  but  a  few  examples  to  illustrate  that  machinery 
hazards  can  be  minimized  by  the  observance  of  proper  hygienic 
rules,  and  that  the  study  of  the  cause  must  not  be  confined  merely 
to  the  machine,  nor  should  the  preventive  be  determined  from  a 
mechanical  standpoint  alone. 

An  authority  on  liability  insurance  informed  me  that  even 
in  Germany,  with  its  rigid  reporting,  he  doubted  whether  half 
the  accidents  were  tabulated,  so  it  is  very  possible  that  many 
accidents  due  primarily  to  results  of  faulty  hygiene  are  not  re- 
ported, and  possibly  would  have  afforded  valuable  data  to  show 
the  relationship  of  hygiene  to  the  machinery  hazard. 

I  would  ask  that  greater  attention  be  given  to  the  questions  of 
hygiene  when  studying  the  cause  of  accidents,  and  that  the 
physician's  advice  be  consulted  before  applying  guards  of  in- 
discriminate type  to  machines  requiring  the  constant  attention 
of  an  operator. 

The  following  figures  may  be  of  interest: 

In  New  York  State  alone  44,309  accidents  were  reported  in 
one  year  (191 1)  of  which  376  caused  death.  27.6  per  cent  occurred 
in  working  machinery,  4.4  per  cent  occurred  in  power  transmission 
machinery.  Of  the  deaths  7.7  per  cent  occurred  in  power  trans- 
mission machinery,  5.1  per  cent  occurred  in  working  machinery. 

In  the  quarter  ending  September,  1913,  6,317  accidents  were  re- 
ported on  mechanical  power  of  which  354  were  on  saws,  126  on 
leather  working  machines,  99  ivory  turning,  53  looms,  47  bottle 
washing,  40  laundry  machines  (burns),  24  carding  (textile),. 
22  spinning  (textile),  23  picking. 


IV. 

MEASURING  THE  COST  OF  CHILD  LABOR. 

I. 

By  ALEXANDER   J-   McKBLWAY,   D.D.,  Secretary  for  Southern  States,  National    Child 
Labor  Committee,  Washington,  D.  C. 

II. 

By  OWEN  R.  LOVEJOY,  LL.D.,  General  Secretary,  National  Child  Labor  Committee,  New 

York  City. 

I. 

Mr.  Chairman,  I  suppose  you  all  recall  the  striking  Scripture 
testimony  to  the  ante-mortem  inefficiency  of  the  doctors  as  well 
as  to  the  post-mortem  efficacy  of  drugs,  this  testimony  being 
found  in  the  Sixteenth  Chapter  of  Second  Chronicles,  as  follows: 

And  Asa  in  the  thirty  and  ninth  year  of  his  reign  was  diseased  in  his  feet 
until  his  disease  was  exceeding  great.  Yet  in  his  disease  he  sought  not  to  the 
Lord  but  to  the  physicians;  and  Asa  slept  with  his  fathers;  and  they  buried 
him  and  laid  him  in  the  bed  which  was  filled  with  sweet  odors  and  divers 
kinds  of  spices  prepared  by  the  apothecaries'  art. 

You  would  doubtless  agree  that  in  the  year  914  B.  C.,  it  would 
have  been  better  for  any  one,  king  or  peasant,  to  seek  the  Lord 
rather  than  the  physicians.  In  the  days  of  Christ,  we  learn  of 
the  woman  who  had  "suffered  many  things  of  many  physicians 
and  was  nothing  bettered  but  rather  grew  worse."  I  suppose 
that  even  coming  down  to  the  year  of  our  Lord,  1784,  you  would 
not  regard  the  opinion  of  the  physicians  of  Manchester,  England, 
as  of  very  great  value  on  individual  diagnosis  or  prognosis.  They 
had  investigated  a  fever  epidemic  at  the  Radcliffe  cotton  works, 
and  while  they  professed  ignorance  of  its  cause,  they  said: 

But  though  this  point  remains  doubtful,  we  are  decided  in  our  opinion 
that  the  disorder  has  been  supported,  diffused  and  aggravated  by  the  ready 

communication  of  contagion and  by  the  injury  done  to  young  persons 

through  confinement  and  too  long-continued  labor,  to  which  several  evils 
the  cotton  mills  have  given  occasion.  We  earnestly  recommend  a  longer 
recess  at  noon  and  a  more  early  dismission  from  it  in  the  evening,  to  all  those 
who  work  in  the  cotton  mills;  but  we  deem  this  indulgence  essential  to  the 
present  health  and  future  capacity  for  labor  for  those  who  are  under  the  age 
of  fourteen;  for  the  active  recreations  of  childhood  and  youth  are  necessary 


32 

to  the  growth  and  right  conformation  of  the  human  body.     And  we  cannot 

excuse  ourselves  on  the  present  occasion  from  suggesting this  further 

very  important  consideration,  that  the  rising  generation  should  not  be  de- 
barred from  all  opportunities  of  instruction  at  the  only  season  in  life  at  which 
they  can  be  properly  improved. 

These  same  Manchester  physicians,  then  constituted  into  a 
Board  of  Health,  in  1796,  passed  the  following  resolutions,  among 
others : 

The  large  factories  are  generally  injurious  to  the  constitution  of  those 
employed  in  them,  from  the  close  confinement  which  is  enjoined,  from  the 
debilitating  effects  of  hot  or  impure  air,  and  from  the  want  of  the  active 
exercises  which  nature  points  out  as  essential  in  childhood  and  youth  to 
invigorate  the  system,  and  to  fit  our  species  for  the  employments  and  for  the 
duties  of  manhood.  The  untimely  labor  of  the  night  and  the  protracted 
labor  of  the  day,  with  respect  to  children,  not  only  tend  to  dimmish  future 
expectations  as  to  the  general  sum  of  life  and  industry,  by  impairing  the 
strength  and  destroying  the  vital  stamina  of  the  rising  generation,  but  it  too 
often  gives  encouragement  to  idleness,  extravagance  and  profligacy  in  the 
parents,  who,  contrary  to  the  order  of  nature,  subsist  by  the  oppression 
of  their  offspring. 

From  the  excellent  regulations  that  subsist  in  several  cotton  factories,  it 
appears  that  many  of  these  evils  may  be  in  considerable  degree  obviated; 
we  are  therefore  warranted  by  experience,  and  are  assured  we  shall  have  the 
support  of  the  liberal  proprietors  of  these  factories,  in  proposing  an  applica- 
tion for  parliamentary  aid  to  establish  a  general  system  of  laws  for  the  wise, 
humane  and  equal  government  of  all  such  works. 

Regarding  the  old  saw  that  prevention  is  better  than  cure  it 
seems  to  me  that  the  doctrine  laid  down  by  the  Manchester 
physicians  is  of  considerable  value.  We  who  have  been  fighting 
for  ten  years  in  the  cause  of  child  labor  reform  have  enlisted  to  a 
large  degree  the  support  of  the  other  two  learned  professions. 
The  pulpit  of  America  speaks  its  mind  freely  on  the  evils  of  the 
child  labor  system,  and  several  thousand  pulpits  unite  in  the 
condemnation  of  the  system  on  what  has  come  to  be  known  as 
Child  Labor  Sunday.  The  members  of  the  bar,  through  the 
American  Bar  Association  and  its  Commission  on  Uniform  State 
Laws,  unanimously  endorsed  what  is  known  as  the  Uniform  Child 
Labor  Law,  containing  the  best  standards  of  existing  statutes 
already  in  force  in  the  United  States,  and  recommended  this 
law  for  adoption  by  all  the  states.  The  same  standards  of  pro- 


33 

tection  for  children  are  included  in  the  Federal  Child  Labor  Law. 

And  now  we  come  to  the  other  learned  profession  and  ask  them 
to  assist  us  in  "Measuring  the  Cost  of  Child  Labor,"  which  is 
the  title  of  the  paper  written  by  the  General  Secretary  of  the 
National  Child  Labor  Committee,  which,  in  his  necessary  and 
regretted  absence,  I  have  been  asked  to  read  to  you. 

II. 

To  measure  the  full  cost  of  child  labor  is  impossible.  There  are 
too  many  elements  in  it  which  are  spiritual,  invisible  to  the  eye, 
and  yet  all  the  more  serious  in  their  effect  upon  us.  As  a  race, 
we  are  hardened — debased — by  accepting  the  habit  of  jobs 
a-plenty  for  children  and  jobs  too  scarce  for  adults.  We  tolerate 
an  order  in  the  industrial  world  which  contradicts  our  high  in- 
stincts for  the  care  of  the  weak" and  the  undeveloped,  and  our 
social  inconsistency  is  as  dangerous  to  the  sound  development 
of  the  social  organism  as  moral  inconsistency  is  dangerous  to  the 
individual. 

The  National  Child  Labor  Committee  believes  that  child  labor 
is  one  important  cause  of  low  wages  and  unemployment  among 
adults  and  our  belief  is  confirmed  by  the  fact  that  wherever 
children  have  been  eliminated  from  an  industry  the  wages  and 
standard  of  living  have  risen.  In  so  far  as  our  assumption  is 
correct,  child  labor  leads  to  under-nourishment  and  over-crowd- 
ing and  an  increased  susceptibility  to  disease  among  all  the  work- 
ers involved.  Like  the  spiritual  costs,  these  indirect  physical 
effects  work  an  injury  to  society  which  is  evident  enough  to  the 
impartial  observer  but  quite  impossible  to  measure. 

To  the  children  themselves  there  are  costs  in  ignorance  and 
inefficiency,  again  obvious  but  difficult  to  reckon.  Of  these  I 
shall  not  attempt  to  speak  but  shall  confine  my  remarks  to  the 
measuring  of  physical  costs  to  the  children.  The  physical  costs 
of  child  labor  to  the  children  have  always  made  the  most  popular 
appeal  against  child  labor  and  I  believe  it  has  been  the  general 
realization  that  no  child  under  14  could  work  in  a  factory  with- 
out serious  physical  harm,  which  has  led  people  to  support  the 
improved  child  labor  laws  that  have  been  passed  since  this  Com- 
mittee was  organized  ten  years  ago.  These  costs  are  so  obvious 


34 

that  to  spend  months  or  years  in  measuring  the  effects  of  child 
labor  by  young  children  in  canneries,  cotton  mills,  factories, 
and  stores,  instead  of  taking  the  children  out  of  industry  without 
delay  would  be  little  short  of  criminal.  That  these  costs  are  well 
understood  and  acknowledged  even  in  those  states  which  do  not 
have  a  1 4-year  limit  in  factories,  mills,  and  canneries,  is  evident 
by  the  arguments  employers  are  offering  nowadays  in  opposi- 
tion to  improved  child  labor  laws.  They  have  been  shamed 
out  of  referring  to  the  benefit  to  their  industry;  they  acknowledge 
that  for  the  children  themselves  the  work  is  not  the  best  possi- 
ble childhood,  but  they  set  forth  an  array  of  specious  defenses, 
greater  evils  beside  which  the  lesser  evil  of  child  labor  may  ap- 
pear necessary  or  even  tolerable. 

But  with  young  children  in  outdoor  work  and  with  older  chil- 
dren in  all  occupations,  we  enter  upon  debatable  ground,  where 
the  need  for  a  careful  study  of  physical  costs  is  urgent.  We 
believe  that  our  present  standards  of  child  labor  legislation — a 
i4-year  limit  in  factories  and  a  dozen  other  common  occupations, 
a  lower  limit  for  newsboys  and  other  street  workers,  and  no  limit 
whatever  for  children  in  the  fields — are  utterly  inadequate,  and 
do  not  protect  the  children  from  physical  harm,  but  we  know 
that  our  opinion  and  perhaps  even  your  opinion  will  hardly  con- 
vince the  public  against  the  tradition  of  generations,  until  the  re- 
lation of  physical  costs  to  such  child  labor  is  established. 

For  instance,  the  newsboy  is  subject  to  a  constant  nervous 
strain  in  the  tension  and  excitement  of  the  streets.  His  hours 
and  meals  are  irregular  and  unwholesome.  If  he  combines  his 
work  with  attendance  at  school  he  is  continually  overdoing. 
Everything  about  his  life  conspires  to  develop  a  taste  for  stimu- 
lants. There  are  moral  dangers  in  his  work,  but  we  believe  that 
on  physical  grounds  alone  street  work  by  children  under  14 — or 
better,  under  16 —  should  be  forbidden. 

We  find  little  berry-pickers  and  cotton-pickers  whose  work 
seems  to  involve  all  the  worst  phases  of  factory  life  except  the 
lack  of  fresh  air;  simple  monotonous  processes  repeated  hour 
after  hour,  day  after  day,  exhausting  one  set  of  muscles  while 
others  are  unused;  and  in  many  cases  the  carrying  of  heavy  trays 


35 

or  boxes  of  fruit  and  bags  of  cotton  which  must  strain  and  injure 
little  bodies.  Are  we  right  in  believing  that  these  and  certain 
other  forms  of  agricultural  work  are  physically  harmful  and  that 
even  a  strict  enforcement  of  school  attendance  laws  would  not 
protect  these  children?  Until  we  can  prohibit  entirely  the  em- 
ployment of  very  young  children  in  all  occupations,  and  all  chil- 
dren under  14  in  the  most  injurious  forms  of  agricultural  work, 
we  should  at  least  supplement  our  school  attendance  laws  with 
special  permits  issued  only  to  those  children  who  come  up  to  the 
standard  in  physical  health  and  in  grade  work. 

You  will  agree,  I  am  sure,  that  a  1 4-year  age  limit  is  a  perfectly 
illogical  and  inadequate  restriction  of  the  age  of  children  enter- 
ing industrial  life.  About  half  of  the  states  have  recognized  that 
14  is  a  compromise  limit  by  excluding  children  of  fourteen  from 
certain  specified  occupations  classified  as  physically  or  morally 
dangerous.  But  with  the  exception  of  Ohio,  which  has  fixed  a 
1 5 -year  limit  for  boys  and  a  1 6-year  limit  for  girls  in  factories 
and  other  common  forms  of  employment,  and  Montana  with  her 
1 6-year  limit  for  all  employed  in  factories  and  as  messengers, 
the  kinds  of  work  forbidden  to  children  under  16  or  18  years 
have  been  selected  from  the  occupations  and  the  types  of  machin- 
ery recognized  as  hazardous  for  adults.  The  physical  costs  on 
which  they  are  based  are  costs  in  accidents  or  in  severe  occu- 
pational disease.  But  we  maintain  that  among  the  kinds  of  work 
permitted  in  practically  all  states  to  children  of  fourteen  there 
are  many  that  are  not  only  dreary  and  monotonous  to  adults  but 
positively  harmful  to  children. 

To  measure  the  costs  of  these  three  forms  of  child  labor — street 
work  and  agricultural  work  by  children  under  14  and  industrial 
work  by  children  over  14 — it  seems  to  me  that  a  study  of  the 
problem  should  be  made  simultaneously  from  three  angles.  We 
must  determine  the  child's  physical  condition  before  he  goes  to 
work,  his  physical  condition  while  at  work,  and  we  must  know 
the  history,  family  and  industrial,  of  minors  who  come  under 
medical  care. 

In  a  few  child  labor  laws,  the  machinery  is  already  provided  by 
the  state  for  a  study  of  the  first  point,  the  physical  condition  of 


36 

the  child  before  he  goes  to  work.  Twenty  states  require  or  per- 
mit a  physical  examination  of  every  child  who  applies  for  a  work 
permit,  although  only  a  few  of  these  interpret  this  provision  to 
mean  a  complete  examination  of  all  children  regardless  of  their 
general  appearance.  Eleven  states,  including  seven  of  these 
twenty,  issue  a  permit  only  for  a  definite,  actual  job,  and  require 
the  child  to  return  for  a  new  permit  when  he  goes  to  a  new  em- 
ployer. Under  such  a  law,  passed  in  1912,  the  Maryland  Bureau 
of  Statistics  and  Information  which  issues  the  permits  for  Balti- 
more City,  examined  in  one  year  1500  boys  previously  employed 
in  factories,  and  found  93  serious  occupational  defects.  This 
month  the  medical  examiner  wrote  me  that  he  had  especially 
examined  for  height,  weight  and  pubic  age,  one  hundred  boys  who 
averaged  fifteen  years  of  age  and  had  been  employed  in  factories 
for  an  average  of  two  years  each.  It  should  be  noted  that  Mary- 
land has  a  fairly  comprehensive  list  of  dangerous  occupations 
forbidden  under  16  years,  so  that  these  boys  were  doing  work 
not  recognized  as  injurious.  He  found  their  average  height 
nearly  one-half  an  inch  lower  than  the  standard  for  fifteen  years, 
which  he  reckoned  as  5  feet  and  i  inch;  their  weight  was  92  and 
52/100  Ibs.  as  against  a  normal  average  of  io63/4  Ibs.;  and  only 
58  per  cent,  were  of  pubic  age. 

In  Ohio,  by  the  cooperation  of  the  school  authorities,  public- 
spirited  citizens,  the  Schmidlapp  Bureau,  and  the  National  Child 
Labor  Committee,  Mrs.  Helen  T.  Woolley  and  her  assistants 
are  now  making  an  extensive  study  of  800  children,  selected  from 
those  who  went  to  work  at  14  years  in  191 1—12,  and  of  a  companion 
group  of  children  of  corresponding  age  who  remained  in  school. 
Tests  are  applied  covering  all  the  details  of  development  and  edu- 
cation and  the  results  will  be  most  valuable  for  the  occupations 
other  than  street  work  of  city  children. 

These  provisions  for  physical  examination  in  connection  with 
a  work  permit  issued  for  a  definite  job,  when  thoroughly  carried 
out,  should  insure  a  normal  development  of  the  child  before  he 
enters  industry.  And  by  excluding  children  who  are  anemic 
and  diseased  this  preliminary  examination  not  only  gives  the  sub- 
normal child  a  better  chance  to  improve  physically,  but  it  clears 


37 

the  ground  for  a  fair  study  of  the  actual  effects  of  industry  upon 
healthy  children.  Until  the  sub-normal  children  are  eliminated, 
we  cannot  assert  that  the  physical  deterioration  of  children  at  work 
is  due  to  the  work  and  not  development  of  the  child's  condition 
before  he  went  to  work,  nor  can  we  demand  for  all  children, 
physically  strong  as  well  as  physically  sub-normal,  a  higher  age 
limit  for  industrial  work. 

A  large  percentage  of  the  children  in  cities  or  towns  with  several 
industries  drift  about  from  one  job  to  another.  In  so  far  as  some 
children  drift  from  one  factory  to  another  factory,  and  others 
change  from  store  to  store,  or  from  errand  boy  here  to  errand  boy 
there,  such  records  as  those  in  Maryland  and  in  any  other  state 
which  applied  thoroughly  these  two  provisions  of  a  child  labor 
law  would  furnish  a  basis  for  comparison  concerning  the  health- 
fulness  of  factories,  and  stores,  and  miscellaneous  jobs,  but  they 
do  not  cover  effects  of  their  work  upon  the  children  who  stick 
to  one  job,  and  they  do  not  supply  material  concerning  special 
industries  until  they  are  supplemented  by  thorough  medical 
inspection  of  the  children  actually  at  work.  Two  states,  Massa- 
chusetts and  New  York,  have  made  a  beginning  of  medical  in- 
spection of  children  in  factories. 

In  Massachusetts,  each  industrial  health  inspector  is  required 
to  inform  himself  concerning  the  health  of  all  minors  employed 
in  factories  within  his  district,  and  whenever  he  may  deem  it  ad- 
visable or  necessary,  he  shall  call  the  ill-health  or  physical  unfit- 
ness  of  any  minor  to  the  attention  of  his  or  her  parents  or  em- 
ployers and  shall  report  it  at  the  State  Board  of  Labor  and  In- 
dustries.  Since  the  law  was  passed  in  1907,  several  thousand 
children  have  been  "seen  and  questioned,"  but  the  number  of 
actual  examinations  has  been  of  necessity  small,  covering  only 
those  whose  appearance  of  ill-health  or  whose  family  history 
has  aroused  the  suspicions  of  the  inspectors.  Hardly  more 
would  have  been  possible  with  the  staff  provided  to  make  this  in- 
spection in  addition  to  other  duties.  It  has  failed  to  protect  all 
the  children  suffering  from  serious  defects,  since  the  inspectors 
have  had  no  power  to  revoke  employment  certificates  and  it  has 
not  furnished  a  basis  for  deductions  concerning  the  less  evident 
forms  of  physical  injury  involved  in  factory  work. 


38 

New  York  has  appointed  three  physicians  to  "inspect  fac- 
tories, mercantile  establishments  and  other  places  throughout 
the  state  with  respect  to  conditions  of  work  affecting  the  health 
of  persons  employed  therein  and  have  charge  of  the  physical  ex- 
amination and  medical  supervision  of  all  children  employed 
therein."  The  inspectors  report  cases  to  the  Commissioner  of 
Labor,  who  has  power  to  revoke  a  certificate  when  he  sees  fit, 
so  that  the  New  York  law  affords  a  little  better  protection  to 
the  children  themselves,  but  the  staff  is  too  small  and  their  duties 
too  numerous  to  furnish  reliable  data  for  generalizations  con- 
cerning children  in  factories. 

There  has  been  one  interesting  study  of  the  industrial  history 
of  minors  who  come  under  medical  care.  In  1911,  the  Massachu- 
setts General  Hospital  recorded  a  complete  set  of  facts  concern- 
ing every  unmarried  working  girl  who  applied  for  medical  relief 
at  the  charitable  clinic  during  eight  months.  It  was  found  that 
the  great  majority  of  them  had  left  school  at  fourteen;  three  at 
the  age  of  ten.  Seven  girls  went  to  work  at  twelve.  The  num- 
ber studied  (only  80  in  all)  was  too  small  to  draw  conclusions  con- 
cerning effects  of  age  and  occupation,  but  a  similar  study  of  both 
sexes  in  several  localities  and  covering  a  longer  period  of  time 
would  give  convincing  evidence. 

There  are  several  ways  in  which  you  can  help  us,  if  you  will, 
to  measure  the  cost  of  child  labor.  These  rudimentary  begin- 
nings suggest  the  line  for  further  activity  in  which  state  agencies 
and  private  medical  organizations  might  well  co-operate,  and  with 
a  minimum  of  effort  arrive  at  valuable  results. 

As  citizens,  and  as  members  of  the  state  medical  associations, 
we  would  ask  you  to  second  our  efforts  to  incorporate  in  the  child 
labor  laws  the  provisions  concerning  physical  examinations  and 
work  permits  to  which  I  have  referred.  Your  active  participa- 
tion in  such  campaigns  would  show  the  public  the  importance 
of  these  apparently  uninteresting  phases  of  child  labor  legisla- 
tion. And  such  provisions  being  on  the  statute  books,  you  doc- 
tors can  in  your  own  localities  do  more  than  any  one  else  to  see 
that  they  are  carefully  and  consistently  applied. 

You  can  help,  again  more  than  any  laymen,  to  secure  the  med- 
ical inspection  of  children  at  work.  I  believe  the  state  medical 


39 

inspectors  in  New  York  and  Massachusetts  would  welcome 
your  co-operation  in  a  detailed  study  of  all  the  children  at  work 
in  special  localities  or  of  all  the  children  at  work  in  certain  indus- 
tries. The  federal  government  has  published  a  volume  on  the 
causes  of  death  among  cotton  mill  operatives  which  show  such  a 
startling  tendency  to  tuberculosis  and  other  pulmonary  diseases 
that  we  should  be  justified  without  further  study  in  classifying 
work  in  a  cotton  mill  as  a  dangerous  trade.  Similar  studies, 
covering  all  minor  operatives  in  other  child-employing  occupa- 
tions, could  be  made  by  the  co-operation  of  private  physicians 
in  different  places,  under  the  guidance  of  a  well-drawn  schedule. 

And  in  the  third  place,  you  can  follow  in  your  clinics  the  exam- 
ple of  the  Massachusetts  General  Hospital.  In  some  industrial 
communities  the  industrial  history  of  those  who  come  for  treat- 
ment would  yield  information  of  the  highest  value  to  your  pro- 
fession as  well  as  to  the  general  public. 

The  public  may  reasonably  ask  why  the  National  Child  I/abor 
Committee  does  not  undertake  these  technical  studies  on  its  own 
account.  But  obviously  no  such  question  could  arise  among 
those  interested  in  this  gathering  because  you  realize,  as  the  lay- 
man cannot,  the  technical  difficulties  of  securing  and  communi- 
cating to  the  public  any  kind  of  information  dealing  with  mat- 
ters of  public  health.  To  have  such  work  carried  on  by  a  propa- 
gandist organization  like  ours,  an  organization  which  in  ten  years 
has  achieved  a  certain  prominence  as  the  aggressive  promoter 
of  child  labor  legislation,  would  tend  to  prejudice  the  results. 
Furthermore,  the  very  need  of  our  activities  precludes  a  patient 
devotion,  at  the  present  time,  to  the  kind  of  scientific  investiga- 
tion referred  to.  So  much  remains  to  be  accomplished  along  lines 
that  are  obvious  to  every  person  of  average  intelligence  that  we 
have  considered  our  duty  to  lie  in  the  direction  of  securing  the  en- 
actment and  enforcement  of  laws  approved  by  popular  intelli- 
gence but  opposed  by  an  equally  popular  self-interest  rather  than 
in  lines  of  scientific  research.  We  believe  the  time  has  now  come 
to  lay  upon  the  conscience  of  the  medical  profession  in  America 
the  duty  of  duplicating  in  our  own  country  the  scientific  study 
upon  the  physical  effects  in  industry,  already  available  in  Euro- 
pean industrial  communities. 


V. 

CAUSES  OF  MORBIDITY  AND  MORTALITY  IN  THE  IN- 
DUSTRIAL PARTURIENT  WOMAN  AND  MEAS- 
URES FOR  IMPROVEMENT. 

By  E.  E.  MONTGOMERY,  M.D.,  LL.D.,  Philadelphia. 

It  is  difficult  to  predict  what  the  future  evolution  of  woman 
will  effect  in  her  association  with  the  home,  but  with  society  as 
at  present  constituted  her  position  in  its  relation  to  her  husband, 
and  her  influence  on  the  future  welfare  of  her  progeny  is  of  the 
utmost  importance.  She  makes  or  mars  the  home-life;  indeed, 
in  a  supreme  degree  she  is  the  home.  A  home  made  attractive 
by  a  wife's  loving  care  and  thought  saves  many  a  man  from  temp- 
tations and  dissipations  which  constantly  dog  his  footsteps. 
Children  recognize  the  home  as  a  haven  from  every  danger  where 
they  are  trained  to  meet  bravely  and  to  overcome  the  trials  and 
obstacles  of  life;  a  mother's  counsel  gives  them  courage  to  meet 
the  difficulties  which  are  inevitable,  and  the  inspiration  to  fight 
life's  battles  with  renewed  energy.  However  hard  her  position 
when  unfitted  by  lack  of  proper  education  and  training  for  the 
superintendence  and  management  of  a  home,  she  is  still  further 
handicapped  by  limited  means,  frequent  child-bearing  and  the 
responsibilites  associated  with  the  training  of  children,  when  all 
her  energies  are  apparently  needed  to  supply  her  children  with 
food.  It  is  sad  to  contemplate  how  little  consideration  is  given 
to  the  education  of  the  ordinary  girl  for  her  actual  work  in  life. 
A  training  in  domestic  science  is  rarely  thought  of  for  a  woman 
unless  she  expects  to  teach,  yet  the  economic  selection  and  prepa- 
ration of  food,  the  recognition  of  the  proper  texture  for  clothing 
and  its  preparation  are  of  vital  importance  to  home-making  and 
spell  success  or  failure  for  the  young  couple  who  so  blithely  start 
on  life's  journey.  Even  when  well  equipped  for  the  trial  the  re- 
sult is  rendered  doubtful  by  every  condition  which  lowers  the 
vitality  of  such  a  worker,  and  renders  her  unable  easily  to  main- 
tain her  proper  equilibrium  so  that  what  would  be  a  pleasurable 
work  of  love  becomes  a  task  too  irksome  for  her  diminishing 


strength  and  produces  a  nervous,  irritable  croaker  whose  presence 
it  is  a  relief  to  escape. 

The  primary  object  of  mating  is  the  propagation  of  the  Race, 
and  the  rightly  constituted  sensible  woman  regards  this  as  her 
highest  function.  Next  to  marriage  probably  no  function  has 
a  greater  influence  upon  her  health,  and  consequently  her  future 
well-being.  It  is  true  that  parturition  is  a  natural  procedure, 
but  through  the  process  of  evolution  woman  has  departed  a  long 
way  from  the  animal  in  her  method  of  delivery,  and  in  its  influ- 
ence on  her  future  welfare.  A  number  of  factors  enter  into  the 
promotion  of  a  successful  and  easy  labor.  The  woman  must 
be  in  good  health  mentally  and  physically.  During  the  period 
of  gestation  her  economy  has  had  to  provide  for  the  nutrition 
and  elimination  of  herself  and  the  offspring  developing  within 
her.  If  her  financial  environment  is  such  that  she  is  unable  to 
provide  herself  with  sufficient  or  proper  food,  if  she  suffers  from 
neglect  or  has  the  realization  that  she  has  lost  or  never  had  the 
love  of  her  life  companion,  if  she  is  constipated  or  suffers  from 
defective  renal  elimination  or  other  disturbances  of  secretion, 
toxemias  are  likely  to  be  produced  which  may  imperil  promise 
of  future  good  health  or  may  endanger  life.  Eclampsia,  which 
is  a  consequent  of  toxemia,  may  cause  the  death  of  mother,  off- 
spring, or  both,  or  it  may  produce  destructive  changes  in  the 
nervous  or  renal  structure  of  the  mother  or  child  which  are  conse- 
quently irreparable. 

The  most  frequent  causes  of  disturbance  in  the  parturient, 
which  are  also  capable  of  prolonged  evil  effect,  are  the  injuries 
which  occur  to  the  birth  canal,  most  frequently  seen  in  the  form 
of  lacerations  of  the  cervix,  vagina  and  pelvic  floor.  By  such 
injuries,  or  even  without  them,  opportunity  is  afforded  for  the 
entrance  of  infection.  Probably  the  woman  living  in  rural  surround- 
ings, whose  life  is  spent  largely  in  the  open,  is  less  likely  to  be  the 
subject  of  infection.  A  life  of  activity  is  not  detrimental  to  the 
woman  approaching  parturition,  but  there  is  a  great  difference 
between  the  activity  conducted  within  doors — in  the  crowded 
city,  possibly  in  crowded  sweat-shops,  ill-ventilated  factories — 
and  the  life  of  the  open  country.  The  conditions  experienced 


42 

by  the  city  women  combined  with  insufficient  or  improper  nour- 
ishment, the  loss  of  rest  and  worry  incident  to  financial  prob- 
lems increase  the  danger  of  infection  through  lessened  resistance. 
Life  in  overcrowded,  ill-ventilated  and  undrained  tenements, 
frequently  an  entire  family  and  even  two  or  more  families  occupy- 
ing one  apartment,  with  no  provision  for  bodily  cleanliness,  with 
insufficient  or  no  bed  linen,  present  conditions  most  unfavorable 
for  procuring  any  degree  of  asepsis,  no  matter  how  efficient  the 
attendant,  but  when  this  state  is  combined  with  the  attendance 
of  incompetent  and  inefficient  midwives,  or  what  is  still  worse, 
by  physicians  who  have  grown  careless  and  who  do  not  feel  that 
the  expected  remuneration  is  commensurate  with  the  trouble  re- 
quired to  provide  proper  safeguards,  is  it  surprising  that  such 
patients  are  subsequently  handicapped  by  the  consequences  of 
infection?  Injuries  go  untreated  and  the  patient  is  obliged  to 
endure  the  consequences,  or  leave  her  child  to  the  care  of  others 
while  she  sojourns  in  a  hospital  for  the  repair  of  conditions  which 
should  have  received  attention  during  her  puerperium. 

When  I  began  the  practice  of  my  profession  the  lying-in  hos- 
pitals were  considered  less  favorable  for  the  parturient  woman 
than  her  home  because  of  the  danger  of  conveying  infection 
from  one  patient  to  another,  from  the  want  of  suitable  provision 
for  the  cleanliness  of  the  confinement  room  and  the  failure  to  ob- 
serve proper  precautions  by  her  attendants.  In  the  Philadel- 
phia Hospital,  nearly  forty  years  ago,  as  was  the  rule,  I  went 
directly  from  my  service  in  the  surgical  wards,  where  there  were 
cases  of  erysipelas  and  other  forms  of  infection,  to  the  obstetric 
department,  and,  naturally,  my  advent  was  followed  by  an  epi- 
demic of  puerperal  fever,  as  it  was  then  called.  Such  expe- 
riences were  of  annual  occurrence  and  it  was  only  when  we  awoke 
to  a  realization  of  the  necessity  of  treating  obstetric  patients 
with  as  much  consideration  as  our  surgical  cases  that  the  occur- 
rence of  puerperal  fever,  or  sepsis,  was  recognized  as  an  avoid- 
able disease.  Its  existence  became  a  reproach;  an  indication 
of  neglect  of  proper  precautions  which  no  medical  attendant 
could  afford  to  ignore,  hence  the  hospitals  for  such  patients 
have  been  made  safe,  and  now  afford  greater  immunity  against 


43 

the  development  of  infection  and  its  sequelae.  Unfortunately, 
the  demands  of  the  home-life,  the  presence  of  other  children  for 
whom  suitable  provision  is  difficult  to  be  secured,  and  other  cir- 
cumstances in  the  life  of  the  industrial  woman  often  render  her 
unable  to  accept  of  the  better  provisions  of  the  obstetric  hospital. 
The  production  of  healthy  men  and  women  is  so  dependent 
upon  the  mother's  health  that  the  pregnant  woman  should  have 
opportunity  afforded  her  to  prepare  for  the  ordeal  of  parturition, 
and  when  her  environment  is  unfitted  to  ensure  her  from  disease 
during  that  period  the  State  should  provide  for  her  and  for  the 
necessities  of  her  children  when  they  cannot  be  otherwise  properly 
cared  for.  Naturally  to  make  such  provision  means  the  expendi- 
ture of  large  sums  of  money  as  well  as  interference  with  the  family 
life  of  the  individual,  but  this  paternalism  has  its  compensation 
in  the  conservation  of  the  health  of  mother  and  offspring  and  the 
State  is  saved  the  care  of  a  race  of  weaklings  who  are  mentally 
and  physically  unfitted  to  successfully  make  the  struggle  of  life. 


VI. 

FATIGUE  AS  AN  ELEMENT  OF  MENACE  TO  HEALTH 
IN  THE  INDUSTRIES. 

By  L.   DUNCAN  BULKLBY,   A.M.,   M.D.,   Physician  to  the  New  York  Skin   and  Cancer 
Hospital,  Consulting  Physician  to  the  New  York  Hospital,  etc.,  New  York  City. 

Fatigue  may  be  healthy  or  unhealthy.  After  a  hard  day's 
labor  or  sport  in  the  open  air  there  is  a  certain  sense  of  fatigue, 
a  desire  to  rest  muscles  which  have  been  put  to  active  service, 
which  is  both  normal,  and  may  even  be  pleasant.  The  result  of 
this  is  increased  and  improved  metabolism,  attended  with  a  greater 
appetite  and  good  digestion  of  proper  food;  the  various  organs  of 
the  body  then  act  readily  to  replace  the  lost  vitality,  and  the 
ultimate  result  is  a  betterment  in  the  general  feelings,  and  under 
ordinary  circumstances  an  improvement  in  health.  The  same 
is  more  or  less  true  in  regard  to  mental  fatigue.  The  proper  use 
of  the  mind  is  school  or  college,  or  in  literary  pursuits,  may  pro- 
duce a  fatigue  which  is  normal  and  which  is  readily  recovered 
from  with  proper  rest  and  sleep,  and  results  in  strengthening 
the  mental  faculties. 

But  it  is  far  otherwise  when  either  in  work  or  recreation  the 
physical  or  mental  fatigue  is  pushed  beyond  a  certain  limit,  and 
when  proper  measures  of  recuperation  are  not  employed ;  and  this 
is  what  constantly  occurs  in  connection  with  many  of  the  occupa- 
tions involving  physical  or  mental  strain,  as  in  the  case  of  opera- 
tions in  various  factories,  school-teachers,  secretaries,  and  others, 
and  which  should  be  guarded  against,  both  for  the  individual's 
well-being  and  for  the  efficiency  of  the  work. 

I.    NATURE   OF   PHYSICAL   AND   MENTAL   FATIGUE. 

What  we  call  fatigue  is  a  nervous  sensation  akin  to  hunger, 
thirst,  dyspnoea,  drowsiness,  etc.,  indicating  that  the  tissues 
have  undergone  a  wasting  process  from  activity,  physical  or  men- 
tal; for  we  must  remember  that  there  is  a  brisk  interchange  of 
substances  going  on  constantly  in  all  parts  of  the  body,  cellular  ele- 
ments being,  continually  destroyed  and  new  ones  formed  to  take 


45 

the  place  of  those  which  have  done  active  service.  While  no  one 
has  actually  seen  this  destruction  and  re-formation  of  tissue  cells, 
the  terms  catabolism  and  anabolism  are  familiar  to  all,  as  indi- 
cating the  chemico-physiologic  processes  by  means  of  which 
these  activities  take  place  through  the  agency  of  the  blood  stream, 
largely  in  the  muscles. 

All  muscular  movement  is  attended  with  the  consumption 
of  material  thus  supplied,  and  with  the  production  of  certain 
waste  products  which  have  to  be  removed;  principal  among  these 
is  carbon  dioxide,  resulting  from  the  combustion  of  sugar,  starch, 
and  fat,  through  the  agency  of  oxygen,  also  supplied  by  the  blood. 
The  failure  to  have  a  full  and  proper  supply  of  these  nutritive 
articles  by  the  blood,  and  of  oxygen,  through  the  lungs,  results 
in  an  excessive  exhaustion  of  muscle  cells  and  a  sense  of  fatigue 
sooner  and  easier  than  should  occur  under  perfectly  normal  con- 
ditions; thus,  fatigue  is  often  a  relative  matter,  depending  more 
upon  the  nutrition  and  vitality  of  the  individual  than  it  does 
upon  the  actual  muscular  exertion  put  forth. 

The  same  is  true  in  regard  to  mental  and  nervous  fatigue, 
for  undoubtedly  the  nerve  cells  of  the  body  undergo  the  same 
changes  as  those  of  the  muscles  under  the  stimulus  of  work,  an 
require  the  same  renewal. 

Human  fatigue,  then,  is  often  the  cry  "enough,"  or  "too  much," 
from  tissues  whose  powers  have  been  taxed  almost  to  a  breaking 
point,  and  neurasthenia  or  "nervous  prostration"  is  a  composite 
condition,  due  to  prolonged  and  excessive  expenditure  of  energy, 
and  is  really  a  later  and  more  pronounced  stage  of  fatigue. 

2.   CAUSES  OF  PHYSICAL  AND  MENTAL  FATIGUE. 

We  have  already  hinted  at  the  basic  cause  of  excessive  fatigue, 
as  a  failure  of  the  system  to  repair  fully  and  promptly  the  wear 
and  tear  of  muscular  or  mental  fiber,  which  may  or  may  not  have 
been  more  than  the  average  healthy  frame  could  or  should  stand. 
And  here,  as  in  so  many  phases  of  life,  the  personal  equation  is 
an  all  important  factor  which  is  commonly  overlooked  or  neg- 
lected. A  load  or  work  which  would  not  be  excessive  for  a  power- 
ful dray  or  farm  horse  will  exhaust  a  lady's  saddle  horse;  while 


46 

again  the  former  can  be  weakened  by  insufficient  food  or  im- 
proper care  so  that  ordinary  work  becomes  excessive,  whereas 
the  latter  can  be  stimulated  by  extra  feeding  and  care,  so  that 
for  a  while,  at  least,  it  can  do  excessive  work  without  undue 
exhaustion. 

It  is  undoubtedly  just  so  in  regard  to  human  work  and  fatigue, 
and  yet,  unfortunately,  in  the  larger  proportion  of  instances  there 
is  relatively  little,  and  often  no  consideration  given  to  the  adap- 
tation of  the  task  of  the  individual,  or  to  the  proper  physical 
or  mental  care  necessary  to  secure  the  highest  efficiency  of  work. 

Thus  the  causes  of  excessive  fatigue  often  rest  also  very  largely 
in  the  individual  and  in  the  conduct  of  life,  which  latter  may  be 
the  result  of  circumstances  beyond  control,  but  perhaps  quite 
as  often  from  ignorance  or  folly.  While  low  wages  undoubtedly 
play  an  important  part  in  many  cases,  leading  to  lowered  nutri- 
tion, and  while  poor  light  and  ventilation  may  contribute  their  quota 
to  the  depressing  effects,  there  is  a  vast  amount  of  ignorance  and 
neglect  of  the  principles  of  diet,  hygiene,  and  sanitation  on  the 
part  of  those  employed,  which  is  often  at  the  bottom  of  the  ex- 
cessive fatigue  which  leads  to  a  physical  and  nervous  break- 
down. If  the  wisest  and  best  principles  of  nutrition  could  al- 
ways be  carried  out  there  is  little  doubt  but  that  the  wages  se- 
cured would  in  most  instances  supply  an  abundance  of  nutrition. 
The  extravagance  and  waste  of  the  poorer  classes  is  proverbial; 
enough  calories  to  carry  on  good  nutrition  could  be  obtained  at 
even  a  fraction  of  the  cost  sometimes  expended  for  food,  if  they 
only  knew  how. 

Also  in  the  matter  of  recreation,  rest,  and  sleep,  those  who 
work  hard  often  fail  entirely  in  securing  the  recuperation  neces- 
sary for  the  renewal  of  their  labors  day  by  day.  The  hours  of 
actual  work  have  been  gradually  lessened,  by  one  means  and 
another,  so  that  now  few  have  hours  which  are  excessive,  but  the 
remaining  time  is  seldom  wisely  spent.  I  speak  from  a  very 
considerable  knowledge  of  workers  of  all  kinds,  physical  and 
mental,  as  I  have  taken  pains  to  investigate  these  matters  for 
years,  in  my  endeavor  to  raise  the  vitality  of  my  patients.  Con- 
tinually I  find  great  carelessness  in  regard  to  the  hours  of  sleep, 


47 

and  rapidity  of  eating,  open-air  exercise,  etc.  Too  few  realize 
that  recreation  is  abused,  and  when  indulged  in  is  rather  wreck- 
reation,  than  re-creation;  I  often  tell  patients  that  the  true 
re-creation  is  found  in  sleep,  and  not  in  theaters,  dancing,  and 
various  amusements  which  interfere  with  the  proper  hours  of 
sleep. 

3.    DAMAGE    TO    THE    INDIVIDUAL    WHEN    NEGLECTED. 

Excessive  fatigue  when  neglected  leads  to  a  depression  of  vital 
powers  to  such  a  degree  that  recuperation  is  not  possible  under  a 
continuance  of  the  same  conditions  of  life  and  work;  indeed  when 
these  are  persisted  in  there  is  a  continued  lowering  of  vitality, 
so  that  each  day  one  is  less  able  to  bear  the  exhausting  fatigue, 
and  thus  a  vicious  circle  is  formed,  often  ending  in  a  complete 
breakdown.  True,  this  is  often  not  recognized  for  a  while,  but 
the  individual,  finding  each  day's  work  harder,  exercises  more 
and  more  will  power,  and,  like  a  hard  master,  forces  the  unwill- 
ing slave  to  do  work,  physical  or  mental,  with  increasing  dis- 
ability until  a  breakdown  occurs. 

Few  grasp  sufficiently  the  fact  that  lowered  vitality  leads  to 
many  diseases  which  either  shorten  life  or  develop  invalidism. 
Surrounded  as  we  are  by  multitudes  of  micro-organisms,  many 
of  which  are  beneficent  and  many  injurious,  a  full  vitality  with 
active  metabolism  makes  proper  use  of  those  favorable  to  life 
but  succumbs  to  those  which  are  harmful.  We  all  know  that 
the  tubercle  bacillus  is  almost  omnipresent,  and  pathologists 
state  that  every  autopsy  can  show  evidence  of  some  slight  in- 
vasion by  this  micro-organism,  and  yet  relatively  few  come 
under  its  full  influence  and  develop  signs  which  can  be  recognized 
as  active  tuberculosis;  and  we  all  recognize  now  that  those  who 
are  thus  affected  are  those  who  suffer  from  lowered  nutrition, 
often  caused  by  prolonged  and  excessive  fatigue.  The  same  may 
be  said  in  regard  to  pus  cocci  and  many  other  microbes,  and  nature 
has  provided  phagocytes  which  in  healthy  blood  continually 
guard  us  against  their  harmful  influence,  but  which  fail  in  this 
duty  when  the  vital  system  is  lowered  by  excessive  fatigue, 
either  physical  or  mental. 


48 

In  operative  work  it  must  never  be  forgotten  that  fatigue  in- 
creases greatly  the  danger  of  accidents  from  machinery,  which 
sometimes  are  of  a  very  distressing  nature. 

4.    INJURY   TO   THE   INDUSTRY. 

Many  of  the  great  industries  are  recognizing  that  efficiency 
of  work  is  best  attained  when  perfect  vitality  of  their  operatives 
is  secured,  and  happily  very  great  advances  have  been  made 
in  many  directions  in  regard  to  reaching  this  end;  but  unfortu- 

,tely  there  are  multitudes  of  other  industries,  great  and  small, 
where  no  such  far-sighted  policy  prevails.  There  is  need,  there- 
fore, of  much  education  and  enlightenment,  not  only  in  the  interest 
of  the  employed  but  also  on  behalf  of  the  industry  or  occupation, 
for  those  who  have  adopted  this  course  testify  to  even  its  great 
pecuniary  benefit  to  all  concerned. 

There  can  be  no  question  that  with  excessive  fatigue  produc- 
tive capacity  is  lessened,  whether  in  physical  or  mental  occupa- 
tions. With  a  lassitude  engendered  by  lowered  vitality,  move- 
ments are  slower  and  less  certain  and  injury  to  fabrics  and  machin- 
ery occur  more  readily,  and  time  is  lost.  The  steel  industry  has 
fully  grasped  this,  through  the  intelligent  and  energetic  work  of 
its  Secretary  for  Welfare,  Dr.  Thomas  Darlington,  late  Health 
Commissioner  of  New  York  City,  who  has  been  the  means  of  im- 
mensely improving  the  health,  social  condition,  and  surroundings 
of  its  operatives. 

It  has  been  my  lot  to  see  and  treat  a  large  number  of  public 
school-teachers,  as  also  secretaries  and  stenographers,  and  others 
engaged  in  mental  pursuits,  who  have  suffered  so  from  fatigue 
that  their  work  has  been  hindered  greatly,  as  many  of  them  recog- 
nize. There  is  certainly  need  of  enlightenment  of  those  who 
are  over  them,  in  order  that  the  greatest  efficiency  may  be  ob- 
tained from  their  efforts. 

5.  REMEDIES. 

Knowing  and  realizing  the  cause  is  the  first  step  toward  recti- 
fying any  evil,  and  in  the  present  instance  the  whole  matter 
may  be  summed  up  in  the  single  word  education,  both  of  the  em- 


49 

ployer  and  the  employed.  But  perhaps  there  should  be  added 
to  this  a  conscientious  appreciation,  acceptance  of,  and  action 
upon  all  the  facts  of  the  case. 

The  employer  should  realize  both  his  moral  responsibility  to 
the  human  beings  whom  Providence  has  placed  under  his  control, 
and  apply  the  Golden  Rule  to  them,  both  for  their  interest  and 
his  own.  The  modern  rush  after  success  has  blunted  the  suscepti- 
bilities of  employers,  who  too  often  grind  down  their  fellow  be- 
ings, so  as  to  get  the  last  drop  of  blood  out  of  them,  with  no 
thought  of  their  welfare  or  really  of  their  own  best  interests. 
When  employers  fully  grasp  and  realize  the  true  facts  of  the  case 
there  will  be  less  fatigue  of  their  employees. 

But  there  is  also  great  room  for  intelligent  education  of  the  em- 
ployees, and  in  this  work  physicians  must  and  should  take  the 
greatest  part.  They  alone  know  the  human  frame  and  what  it 
can  stand,  and  they  alone  are  capable  of  warning  and  properly 
instructing  workers  in  all  fields,  physical  and  mental,  as  to  the 
proper  conservation  of  their  energies.  It  is  our  duty,  line  upon 
line  and  precept  upon  precept,  to  instruct  workers  in  regard  to 
diet  and  hygiene,  to  warn  those  who  are  slowly  yielding  to  fatigue, 
and  to  so  regulate  their  lives  that  their  efficiency,  both  in  the 
present  and  future,  may  not  be  impaired.  From  very  consider- 
able experience  I  believe  that  this  can  be  done,  and  if  we  physi- 
cians take  every  opportunity  of  warning,  teaching,  and  guiding 
all  who  may  come  under  our  influence  in  regard  to  the  princi- 
ples of  healthy  living  there  will  be  fewer  instances  of  injury  of 
all  kinds  from  fatigue. 

531  MADISON  A  vs. 


VII. 
LIGHT  IN  THE  INDUSTRIES. 

By  EDWARD  JACKSON,  M.D.,  Denver,  Colorado. 

To  speak  of  the  "menace  to  health  from  light  in  the  industries"' 
suggests  the  school-boy's  statement  that  "salt  is  what  spoils  the 
bread,  when  the  cook  leaves  it  out."  Light  hurts  the  eyes  when 
they  do  not  get  enough  of  it.  Any  one  who  has  attempted 
photography  knows  the  enormous  difference  between  indoor  and 
outdoor  exposures.  The  film  or  plate  that  gives  a  good  negative 
in  one-twenty-fifth  of  a  second  outdoors,  requires  one  or  several 
seconds  indoors  by  good  daylight,  and  as  many  minutes  by 
artificial  illumination.  The  actinic  effect  of  good  outdoor  light 
is  many  times,  or  many  hundreds  of  times,  as  great  as  that  of 
ordinary  indoor  illumination. 

Outdoor  industries  present  no  problems  as  to  illumination, 
except  when  carried  over  into  the  hours  of  natural  darkness.  The 
farmer,  the  sailor,  the  man  digging  in  the  ditch  make  no  com- 
plaint of  the  light  in  which  they  work.  //  outdoor  light  is  com- 
plained of  it  is  by  the  indoor  worker,  who  suffers  not  from  ex- 
cessive light,  but  from  excessive  contrast.  The  adaptive  power 
of  the  eye,  by  which  light  varying  thousands  of  times  in  photo- 
metric power  is  yet  serviceable  for  vision,  can  be  impaired  by 
habitually  deficient  illumination,  or  strained  by  excessively 
great  or  sudden  demands  upon  it. 

Contrasts  become  a  source  of  inconvenience  or  actual  pain. 
These  we  always  associate  with  the  active  processes  of  light 
adaptation,  feeling  the  bright  light  to  be  excessive.  The  glaring 
street  lights,  so  unpleasant  at  night,  would  scarcely  be  noticed, 
much  less  cause  discomfort,  if  turned  on  at  mid-day.  Many  of 
us  have  noticed  how  different  from  their  glare  at  night  is  the  soft 
effect  produced  when  they  are  turned  on  in  the  twilight.  To  go 
from  a  dark  interior  into  full  noon-day  sunlight  is  always  un- 
pleasant. But  the  gradual  transitions  of  the  night  and  day  out 
doors  are  noticed  only  with  pleasure.  Excessive  contrast,  either 


simultaneous  or  successive,  is  responsible  for  nearly  all  the  fear  of 
bright  light. 

Bright  light  falling  not  on  the  thing  looked  at,  but  directly 
on  the  eye  from  near  the  direction  it  is  looking,  causes  con- 
traction of  the  pupil,  lessens  the  light  received  from  the  object 
we  are  endeavoring  to  see;  and  thus  actually  makes  it  more 
difficult  to  see,  besides  causing  the  discomfort  of  contrast.  Look- 
ing directly  at  the  sun  without  protective  glasses,  or  at  an  acci- 
dental brilliant  electric  flash  may  injure  the  retina.  But  these 
scarcely  figure  in  the  industries,  where  the  danger  is  practically 
always  from  deficiency  not  from  excess  of  light. 

As  to  the  quality  of  the  light,  as  regards  its  color  or  wave  length, 
we  are  now  in  an  era  of  investigation  and  experiment.  Of  the 
results  thus  far  arrived  at  it  is  only  needful  to  say  that  they  seem 
to  agree  entirely  with  what  would  be  expected  on  the  evolutionary 
hypothesis ;  that  the  mixture  we  know  as  white  light,  the  ordinary 
daylight,  is  the  light  to  which  the  eye  is  best  adapted;  and  that 
the  center  of  the  solar  spectrum,  the  yellowish  green,  is  the  most 
efficient  portion.  The  relative  harmfulness  of  ultra-red  and  ultra- 
violet rays  still  remains  debatable.  Daylight  is  best.  The 
shifting  of  the  hours  of  labor  to  secure  it  in  a  greater  proportion 
of  the  working  day  is  a  real  hygienic  measure  that  has  recently 
been  put  into  effect  in  some  of  our  cities.  If  daylight  is  not 
obtainable,  then  the  closest  possible  imitation  of  it  is  the  ideal 
to  be  aimed  at. 

Steadiness  of  illumination  is  extremely  important.  Superior 
steadiness  is  a  great  advance  that  incandescent  mantles  and  fila- 
ments have  made  over  flames,  and  arc  lights.  Adaptation  is  the 
power  that  enormously  extends  the  usefulness  of  our  eyes,  and  it  is 
brought  into  play  with  every  change  in  the  illumination  to  which 
they  are  exposed.  To  the  dark-adapted  eye  bright  light  is 
dazzling  and  unpleasant.  To  the  light-adapted  eye  feeble 
illumination  is  insufficient  and  baffling.  The  rapid  variation 
of  the  brilliancy  of  light  catches  the  eye  always  adapted  to  the 
other  sort  of  illumination,  and  therefore  at  a  disadvantage. 

One  other  quality  of  illumination  must  be  noticed:  Is  the  light 
diffuse  or  concentrated?  Does  the  needed  light  come  from  a 


52 

large  area,  or  from  a  single  point?  The  more  concentrated  it  is, 
the  more  brilliant  that  small  area  must  be,  to  furnish  enough 
light;  and  the  stronger  will  be  the  contrast  with  surrounding 
darkness,  and  the  more  unpleasant  and  harmful,  if  the  source  of 
light  is  placed  where  it  can  send  rays  directly  into  the  eye.  Even 
if  the  eye  is  effectively  shielded  from  the  source  of  light,  sharp- 
ness of  contrast  is  generally  to  be  avoided.  Here  is  where  in- 
direct lighting  systems  show  superiority.  For  reading,  writing, 
and  many  other  kinds  of  work,  diffuse  illumination  is  best.  But 
it  is  not  best  for  all.  In  sewing,  with  thread  having  the  same  color 
as  the  material  on  which  it  is  used,  or  in  reading  from  the  fine 
graduation  of  a  metal  or  glass  scale,  sufficient  contrast  may  only 
be  obtainable  in  a  light  that  gives  strong  sharp  shadows.  In 
respect  to  concentration  or  diffusion,  the  light  must  be  adapted 
to  the  particular  work  that  is  to  be  done  by  it. 

The  direction  in  which  the  light  falls  upon  the  work  is  of  very 
great  importance.  Generally  it  should  come  from  above  and 
behind  the  worker.  The  relations  of  the  eyes,  hands,  and  working 
position  of  the  body  are  such  that  our  work  is  mostly  in  front  of 
us,  below  the  level  of  the  eyes.  Light  coming  from  above  and  be- 
hind falls  fully  on  the  side  of  the  object  we  look  at,  on  the  part 
to  which  the  worker's  attention  is  directed. 

If  it  come  from  squarely  behind,  the  shadow  of  the  head  or  body 
will  be  thrown  on  the  work.  But  it  may  come  over  one  shoulder, 
either  shoulder  except  for  writing  and  work  of  that  sort.  If  it 
came  from  over  the  right  shoulder  when  writing  in  the  ordinary 
manner,  the  shadow  of  the  hand  would  be  thrown  about  the 
point  of  the  pen.  Therefore  the  common  rule  is  to  have  it  come 
from  over  the  left  shoulder.  But  in  general  the  light  must  come 
from  above.  For  fine  work,  that  from  time  to  time  the  worker 
must  bend  down  to  see,  from  above  is  the  only  direction  that  light 
can  come  to  be  of  any  service.  It  is  light  coming  from  above, 
from  which  the  eye  is  best  protected  by  brow  and  lashes  against 
the  harm  from  dazzling  by  light  shining  directly  into  the  eye. 

Fortunately  in  providing  for  artificial  illumination  this  re- 
quirement of  having  it  come  from  above  is  generally  met.  Some- 
times it  is  not  so  far  above  the  worker  as  to  save  the  eyes  from 


53 

direct  rays;  but  the  benefit  of  shading  the  eyes  from  the  source 
of  light  is  coming  to  be  understood,  the  inverted  gas  mantle  is 
so  well  worked  out,  the  electric  lamp  is  so  easily  suspended  from 
above,  the  ceiling  offers  such  a  convenient  and  natural  means  of  in- 
direct illumination,  that  with  artificial  illumination  this  matter 
of  the  direction  in  which  the  light  should  fall  upon  the  work  is 
likely  to  be  well  taken  care  of. 

But  for  the  supply  of  daylight  no  such  rational  provision  has 
been  made.  Our  dwellings  and  our  workshops,  in  the  way  they 
are  lighted,  still  bear  marks  of  similarity  to  the  primitive  huts  or 
the  caves  in  which  our  ancestors  may  have  stored  their  posses- 
sions, or  taken  refuge  from  storm  or  cold  and  enemies  by  night, 
but  in  which  they  never  planned  to  spend  their  days  and  do 
exacting  eye- work.  The  light  coming  in  horizontally  from  a 
distant  window,  or  falling  on  the  floor,  and  thence  diffused  upon 
the  ceiling,  before  it  can  be  reflected  on  the  work  is  much  more 
suggestive  of  the  light  coming  in  from  the  mouth  of  a  cave,  than 
of  any  scientific  arrangement  for  efficient  illumination.  In  the 
building  of  to-day  there  is  still  too  much  of  the  castle,  planned 
chiefly  for  defence;  or  the  monastery  designed  to  favor  intro- 
spection rather  than  observation. 

While  the  illuminating  engineers,  seeking  to  introduce  new 
systems  securely  covered  by  patents,  have  enormously  improved 
the  means  at  command  for  artificial  lighting,  no  such  service  has 
been  rendered  with  regard  to  plans  for  utilizing  the  best,  cheapest 
and  most  general  source  of  light,  ordinary  daylight.  Almost 
the  only  attempts  to  have  daylight  fall  in  the  right  direction  on 
work,  have  been  by  skylight,  available  for  only  a  single  story, 
or  by  utilizing  a  single  favorable  position  close  to  a  north  window. 
For  the  south  side  of  a  building,  where  the  greatest  amount  of 
light  is  available,  the  practical  suggestion  has  been  to  exclude 
light  by  shades  or  to  wall  it  up  solidly,  to  save  the  eyes  from  the 
unpleasant  contrast  of  the  strongly  lighted  floor. 

Bad  as  has  been  our  architecture  as  regards  the  indoor  use 
of  daylight,  it  has  been  supplemented  by  the  daily  practice  with 
regard  to  the  exclusion  from  our  buildings  of  such  light  as  might 
get  in  through  the  openings  left  to  look  out  of.  Shades  are  hung 


54 

so  as  to  cut  off  the  light  from  the  upper  part,  the  only  part  of  the 
window  valuable  for  indoor  illumination.  "Blinds"  are  made 
to  give  alternate  streaks  of  light  and  darkness  emphasizing  the 
annoyance  of  contrasts.  And  in  work-shops  dust  is  generally 
allowed  to  accumulate  on  glass  windows,  until  their  capacity  to 
admit  light  is  cut  down  to  one-half  or  one-tenth  of  what  it  might 
be.  When  all  this  occurs  inside,  little  thought  will  be  given  to 
what  is  outside  the  window,  whether  it  be  clear  sky,  a  dark  wall, 
or  a  tree. 

There  is  danger  in  the  industries  from  the  tendency  to  make 
inadequate  provision  for  daylight;  and  then  to  depend  on  arti- 
ficial illumination.  Artificial  illumination  is  mitigated  darkness. 
Properly  planned  it  may  serve  in  a  way  the  purposes  of  ocular 
labor,  but  it  serves  but  poorly  the  more  general  purposes  of  life. 
Life  can  exist  in  darkness,  but  poorly  and  on  a  lowered  plane. 
Aside  from  their  rudimentary  eyes  cave-dwelling  species  are 
generally  of  less  perfect  organization  than  the  nearly  related 
species  that  dwell  on  the  surface  of  the  earth. 

The  connection  of  pigmentation  with  general  nutritive  pro- 
cesses is  a  deep  and  essential  one  running  back  to  primitive  forms 
of  life.  Sensitiveness  to  light  is  one  of  the  general  properties  of 
living  matter.  Light  must  be  placed  with  temperature  and 
oxygen  as  an  essential  condition  of  any  high  organic  development. 
Buried  in  our  language  are  the  results  of  countless  experiences 
of  the  race;  a  "bright  prospect,"  a  "sunny  disposition,"  "radiant 
with  joy,"  are  phrases  that  with  their  opposites,  a  "dark  out- 
look," "black  despair,"  a  "clouded  life,"  illustrate  the  general 
need  for  light,  the  depressing  effect  of  clouds  and  darkness. 
"Bad  weather,"  a  "perfect  day"  each  carries  its  implication  as 
to  light,  and  they  have  definite  meanings  to  all  of  us.  We  may 
have  blunted  our  pleasure,  diminished  our  capacity  for  enjoyment 
of  outdoor  living,  but  none  of  us  has  reversed  the  race  estimate 
of  light  and  shadow. 

It  is  worth  while  to  consider  how  far  the  worker  has  been  de- 
prived, by  habitual  indoor  living  with  deficient  daylight,  of  the 
benefits  of  the  general  influence  of  light  on  nutrition,  and  its 
value  in  cheerfulness,  hope,  courage,  and  quickened  intellectual 


55 

processes.  Certainly  the  seriousness  of  the  waste  must  be  noted 
with  the  newer  demands  for  efficiency.  This  consideration  alone 
is  sufficient  reason  for  totally  revising  our  provisions  for  daylight 
indoors;  aside  from  the  more  definite  and  better  understood  de- 
mands for  such  revision  that  arise  from  accidents  from  machinery 
poorly  illuminated,  or  the  injury  to  the  eye,  and  the  strain  on  its 
related  parts  of  the  nervous  system  caused  by  working  by  in- 
ferior light. 

The  menace  to  health  as  regards  light  in  the  industries  is  the 
utter  disregard  of  the  essential  principles  of  illumination  by 
daylight,  and  the  tendency  to  substitute  for  daylight  artificial 
light  which  enables  the  work  to  be  done,  but  leaves  the  worker 
the  worse  for  it,  deprived  of  the  general  benefits  of  natural 
illumination  essential  to  a  high  standard  of  permanent  health. 

The  stimulated  and  excessive  growth  of  land  values  in  cities, 
causing  the  erection  of  high  buildings  without  any  attempt  to 
control  their  effect  on  daylight  illumination,  by  building  re- 
strictions, requiring  correspondingly  wide  spaces  between  them, 
and  the  perfecting  of  artificial  lighting  for  technical  use,  without 
any  attention  to  a  scientific  system  of  introducing  daylight  into 
our  buildings,  raises  a  real  danger  to  health  that  ought  to  be 
considered  and  dealt  with. 

The  most  important  step  now  to  be  taken  is  the  abundant 
lighting  with  daylight  of  the  upper  part  of  our  rooms,  from  which 
direction  its  benefits  can  be  enjoyed  without  annoyance  to  our 
over  sensitized  indoor  eyes.  At  the  same  time  a  high  regard 
for  health  would  compel  us  take  as  many  of  our  industries  as 
possible  into  the  conditions  of  outdoor  light  and  open  air. 

This  is  scarcely  the  occasion  to  discuss  particular  industries 
and  conditions.  But  the  harm  of  deficient  illumination  shown 
most  strikingly  in  the  diseased  eyes  and  pale  faces  of  mine  workers, 
or  the  victims  of  sweat-shops,  is  a  menace  only  less  in  degree  to  all 
whose  lives  are  spent  indoors,  removed  from  the  influence  of  normal 
daylight. 


VIII. 
HEAT  AND  VENTILATION. 

By  JOHN  ROACH,  Inspector  of  the  Department  of  Labor  of  the  State  of  New  Jersey,  Trenton. 

The  question  of  properly  heating  work  rooms  is  one  of  the  most 
serious  importance  and  has  engaged  the  earnest  attention  of  the 
engineering  profession.  The  question  of  providing  mechanical 
heating  has  been  given  some  consideration  by  State  Departments 
of  Labor  but  probably  has  not  been  worked  out  so  that  positive 
specifications  could  be  issued  that  would  cover  a  variety  of  work 
shops.  Quite  generally  I  think  engineers  have  agreed  that  the 
following  room  temperatures  are  acceptable  : 

Public  buildings,  68  to  72  degrees. 

Machine  shops,  60  to  65  degrees. 

Foundries,  50  to  60  degrees. 

In  printing  establishments  where  a  high  temperature  is  re- 
quired on  account  of  the  necessity  of  greater  heat  to  make  the  ink 
run  true,  a  temperature  of  from  82  to  90  degrees  is  necessary. 

Generally  the  law  covering  heating  in  the  various  states  says 
that  work  shops  shall  be  heated  in  a  satisfactory  manner.  This 
may  mean  little  or  nothing.  If  the  workers  can  stand  the  tem- 
perature they  will  work,  if  they  can  not  they  will  go  home.  The 
employer  who  wishes  to  get  the  best  work  from  his  workers  will 
study  the  nature  of  the  work  and  the  comfort  of  the  worker  to 
do  his  best  under  a  set  condition.  The  New  Jersey  law  simply 
requires  workrooms  to  be  suitably  heated.  Under  ordinary 
circumstances  this  is  not  hard  to  do  for  no  money  is  to  be  made  in 
maintaining  cold  work  rooms  with  numb-fingered  workers  who  are 
unable  to  give  a  good  account  of  their  day's  labor. 

FOUNDRY. 

In  foundries  the  problem  of  providing  proper  heat  is  much  more 
acute,  for  foundry  buildings  are  generally  so  large  that  the  question 
of  heat  is  a  most  important  factor.  Many  foundries  depend  on 
direct  radiation  from  steam  pipes  along  the  sides  of  the  foundry 
room  and  in  case  of  extreme  cold  weather  they  persist  in  using  an 


57 

open  type  of  coal  or  coke  burner  known  as  a  "salamander." 
In  New  Jersey  the  use  of  the  "salamander"  is  discouraged  for  the 
fumes  from  the  fires  poison  the  air  and  workers  can  not  do  their 
best  when  working  under  such  conditions.  All  open  stoves  must 
be  piped  to  the  outer  air  and  where  traveling  cranes  are  used  this 
offers  another  problem  to  be  considered.  The  question  of  pro- 
viding sufficient  heat  for  foundries  has  been  met  by  the  instal- 
lation of  blower  systems  that  distribute  a  sufficient  quantity  of 
heated  air  throughout  the  foundry  room  at  a  velocity  of  from 
300  to  500  feet  per  minute  and  that  maintain  nearly  an  even 
temperature  of  from  55  to  60  degrees.  In  a  recent  conference 
on  this  subject  that  was  held  between  the  Commissioner  of  Labor 
and  a  Foundry  men's  Association  the  very  interesting  point  was 
brought  out  that  the  proper  heating  of  a  foundry  was  not  only 
healthful  to  the  employees  but  more  economical  to  the  employer. 
The  works  manager  of  a  very  large  foundry  located  in  New 
Jersey  stated  that  when  his  firm  was  using  the  old  type  of  open 
stove,  or  "salamander,"  it  cost  about  thirteen  dollars  per  day 
in  cold  weather  to  provide  a  sufficient  amount  of  heat.  A  blower 
system  for  furnishing  heat  was  installed  and  the  exhaust  steam 
from  the  boilers  was  used,  with  the  result  that  this  expense  was 
eliminated  and  the  only  cost  incurred  was  the  initial  cost  of 
installation  which  was  about  thirty-five  hundred  dollars. 

FOUNDRY  VENTILATION. 

A  system  of  heating  of  this  kind  is  not  only  useful  for  providing 
heat  but  it  aids  materially  in  freeing  a  foundry  of  dangerous 
gases  generated  by  the  process  of  casting  molten  metal.  A 
properly  designed  system  will  do  very  much  more  than  heat  a 
foundry.  One  of  the  serious  questions  confronting  foundrymen 
is  the  question  of  providing  a  free  exit  for  fumes.  In  some  cases 
exhaust  fans  have  been  installed  but  these  have  proved  to  be 
inadequate.  Foundries  have  such  a  large  cubical  content  that 
exhaust  fans  make  practically  no  impression  on  them.  The  best 
method  for  moving  gases  and  vapor  out  of  a  foundry  is  to  have 
a  monitor  running  the  entire  length  of  the  foundry  roof,  with 
windows  hung  on  pivots  that  can  be  easily  opened  from  the 


/ 


58 

foundry  floor.  Pipes  should  be  arranged  throughout  the  room 
so  that  an  equitable  air  pressure  can  be  introduced  and  this 
introduction  of  air  on  a  breathing  line  with  the  worker  will  lift 
the  fumes  and  gases  out  through  the  monitor. 

FACTORY  HYGIENE. 

Probably  the  most  difficult  problem  for  the  various  Depart- 
ments of  Labor  to  solve  is  not  the  safeguarding  of  machinery  or 
fire  prevention  or  protection.  These  matters  are  undoubtedly 
important  but  the  impression  is  beginning  to  gain  ground  that  the 
question  of  factory  hygiene  is  yet  more  essential  to  the  worker. 
The  fact  that  this  is  not  generally  understood;  that  the  fight 
against  industrial  disease  is  practically  new  in  America;  that  not 
only  employers  but  the  workers  themselves  have  accepted  the 
doctrine  that  certain  trades  are  inherently  dangerous,  gives  the 
public  no  clue  to  the  tasks  which  confront  Departments  of  Labor. 

The  Department  of  Labor  of  New  Jersey  has  not  proceeded  on 
any  general  theory  of  providing  certain  air  changes  and  air  condi- 
tions in  factories  in  order  to  safeguard  the  health  of  operatives. 
It  has  endeavored  to  control  and  remove  all  dangerous  dusts, 
heat  and  gases  at  the  point  where  they  are  generated  in  trade 
processes  before  they  have  an  opportunity  of  injuring  the  worker. 
A  very  interesting  statement  was  submitted  to  the  Department 
by  the  secretary  of  the  Polishers  and  Buffers  Union  of  Newark  in 
this  connection.  The  statement  showed  that  the  death  rate  from 
tuberculosis  in  this  trade  was  50  per  1000  in  1904.  In  1913  the 
death  rate  was  6  per  1000.  The  blower  law  which  requires  all 
buffing  and  polishing  wheels  to  be  provided  with  an  exhaust 
system  to  remove  dust  went  into  effect  in  1904.  It  is  not  at  all 
unreasonable  to  assume  that  when  this  law  shall  have  had  time  to 
operate  perfectly  that  the  death  rate  from  tuberculosis  in  this 
trade  can  be  reduced  to  a  minimum. 

/  There  is  no  form  of  suffering  so  terrible,  more  needless  or  more 
destructive  of  future  usefulness  than  the  insidious  lead  dust,  or 
lead  fumes  met  with  and  ignored  on  every  hand.  Mercury 
poisoning,  producing  anemia  and  a  peculiar  sort  of  palsey  known 
as  mercurial  shakes,  has  existed  in  Newark  and  Orange  hat 


59 

factories  for  half  a  century.  Efficient  exhaust  systems  are  now 
being  installed  to  control  and  remove  dust  and  fumes  at  the  point 
where  they  are  generated  which  will  probably  prevent  a  re- 
currence of  these  ills.  In  the  lead  smelters,  regulations  are  being 
introduced  that  will  care  for  the  dusts  and  fumes  that  in  the  past 
have  created  havoc,  and  washing  facilities  must  be  provided  to 
enable  the  workers  to  safeguard  their  health  properly.  How 
acute  the  need  for  these  reforms  are  may  be  gained  from  a  knowl- 
edge of  the  fact  that  one  sweater  furnace  in  New  Jersey  has  a 
record  of  seventeen  victims  of  paralysis  during  the  past  five  years. 
Two  brothers  have  been  victims  of  wrist  drop,  among  this  number. 
One  lead  kettle  in  a  pipe  works  has  produced  two  cases  of  paralysis 
and  three  of  lead  colic.  The  charging  gang  of  a  lead  blast  furnisht 
scores  of  victims  of  colic  and  paralysis  representing  from  ten  to 
twenty  days  work  only. 

In  the  years  that  are  past  a  large  part  of  the  industrial  poison- 
ing resulted  from  an  ignorance  of  the  dangerous  nature  of  trade 
compounds.  The  workers  were  not  aware  of  the  hazards,  and  the 
general  public  were  too  busy  with  their  own  affairs  to  be  interested. 
In  New  Jersey,  however,  a  careful  survey  has  been  made  of  a 
number  of  dangerous  trade  processes,  notably  the  dry  .color 
houses,  smelters,  brass  foundries,  metal  polishing,  rubber  mills, 
cotton  and  flax  mills,  printing  trades  and  lead  industry  with  a 
view  of  determining  the  best  methods  to  safeguard  the  worker. 
f  While  it  may  seem  a  far  cry  from  these  matters  to  the  subject 
of  proper  ventilation  still  I  think  practical  men  will  agree  if  we 
keep  dangerous  fumes  and  dusts  from  coming  in  contact  with  the 
worker  we  will  have  gone  a  long  way  to  eliminate  many  of  the 
\  hazards  that  surround  occupations. 

During  the  year  ending  October  31,  1913,  the  Department  of 
Labor  had  1900  buffing  and  polishing  wheels  covered  with  ex- 
haust systems  of  the  most  efficient  type.  In  addition  to  this 
750  wheels  were  under  contract  for  the  new  system.  The  ex- 
haust system  used  in  New  Jersey  requires  a  very  strong  air 
suction  and  was  the  first  of  its  kind  to  be  adopted  in  this  country. 
In  the  old  days  very  little  attention  was  given  to  exhaust  systems 
and  Departments  of  Labor  were  generally  quite  willing  to  accept 


6o 

any  kind  of  piping.  Under  the  New  Jersey  specifications,  ex- 
haust systems  must  develop  a  suction  sufficient  to  raise  2  inches 
of  water  in  a  U-shaped  tube  within  15  inches  of  the  hood.  This 
positively  insures  the  control  of  any  kind  of  dust  or  fumes. 

In  the  control  of  fumes  a  special  type  of  hood  is  used  and  an 
air  movement  equivalent  to  1000  feet  per  minute  is  required. 
Specific  standards  have  been  establisht  for  all  kinds  of  fumes 
and  dust  removal  so  that  a  manufacturer  when  he  is  ordered  to 
correct  a  certain  evil  may  know  just  how  to  do  it.  In  the  metal 
novelty  trade  large  quantities  of  nitric,  muriatic  and  sulphuric 
acids  are  used  as  a  part  of  the  trade  process:  ducts,  designed  to 
draw  these  fumes  away  from  the  tanks  or  jars  where  the  acids 
are  used  and  before  they  shall  have  had  time  to  pollute  the  air 
that  is  breathed  by  the  worker,  are  being  installed. 

In  the  old  days,  owing  to  faulty  construction,  hoods  used  for 
this  purpose  were  a  menace  rather  than  a  help  to  the  worker; 
the  fumes  were  drawn  up  on  the  breathing  line  and  then  out 
through  the  hood.  Now  the  idea  is  to  draw  the  fumes  away 
from  the  face  of  the  worker  before  he  has  a  chance  to  breathe 
them.  Until  very  recently  in  the  hatting  industry  the  question 
of  steam  control  in  the  sizing  or  plank  shop  seemed  impossible 
of  settlement.  In  wet  weather  or  cold  weather  the  steam  from 
the  sizing  tanks  would  gather  in  such  quantities  that  it  would  be 
impossible  to  distinguish  a  human  form  at  a  distance  of  three 
feet.  Men  worked  in  this  steam-laden  atmosphere  for  nine 
hours  a  day.  As  a  consequence  rheumatism  and  tubercular 
troubles  prevailed  and  one  large  insurance  company  established 
rates  so  high  as  to  be  practically  prohibitive.  After  an  in- 
vestigation covering  a  period  of  about  two  years  the  Department 
of  Labor  adopted  specifications  covering  the  installation  of  ex- 
haust systems  to  abolish  this  evil.  A  number  of  these  installa- 
tions have  been  made  and  conditions  in  plank  shops  are  very 
greatly  improved.  Dust  conditions  in  hat  shops  have  been 
covered  by  specially  designed  exhaust  systems  so  that  it  is  only 
fair  to  assume  that  the  hat  workers'  health  can  be  so  protected, 
as  to  make  the  work  reasonably  safe. 


IX. 

CROWDING,  IN  RELATION  TO  THE  HEALTH  OF  WORK- 
ING PEOPLE. 

By   CHARLES   RICHMOND   HENDERSON,    D.D.,   PH.D.,   Prof,   of   Sociology,    University  of 

Chicago. 

This  is  a  non-medical  social  worker's  plea  for  the  counsel,  help 
and  authoritative  direction  of  community  effort  to  battle  with  a 
serious  and  growing  evil. 

The  plan  of  this  discussion  requires  each  writer  to  isolate  a 
cause  of  physical  injury  which  in  fact  cannot  be  isolated  except 
in  imagination.  Crowding  is  an  evil  which  belongs  in  a  system 
of  evils,  each  of  which  is  reverberated  in  all  the  others.1  Therefore 
the  emphasis  of  one  aspect  may  seem  to  be  exaggerated,  unless 
the  circumstances  of  the  discussion  are  kept  in  mind.  The  other 
papers  will  correct  any  want  of  balance  in  this  contribution. 

This  topic  is  placed  under  "miscellaneous"  factors  in  physical 
conditions  surrounding  the  operation,  and  crowding  is  treated 
in  the  analysis  as  coordinate  with  light,  heat  and  ventilation, 
noise,  food,  home  surroundings,  improper  recreations,  drug 
abuse. 

Crowding  is  an  inevitable  consequence  of  increase  of  popula- 
tion and  the  formation  of  industrial  towns  about  huge  shops, 
mills  and  mines.  Land  does  not  stretch  with  growth  of  popula- 
tion. As  land  rises  in  value  the  temptation  to  crowd,  to  save 

1  The  complexity  of  causes  and  the  contradictions  in  statistics  are  only  too  apt  to 
cause  scepticism  about  the  reality  or  importance  of  crowding.  After  giving  some  of  those 
vexing  figures  which  obscure  this  factor  the  American  Journal  of  Public  Health  (Feb., 
1914,  p.  131)  concluded:  "For  decency's  sake,  for  morality  and  for  ethical  reasons,  the 
demand  for  better  housing  should  never  cease,  but  sanitarians  must  begin  to  divert  atten- 
tion to  racial  and  other  factors  of  population."  When  attention  of  the  public  is  shunted 
off  the  main  track  into  this  swamp  of  race  trails  we  can  hardly  hope  for  progress  short 
of  the  millenium.  Professor  Boas  seems  to  have  shown  us  that  supposed  "race  traits" 
are  changed  in  a  generation  of  greater  comfort  and  good  feeding.  And  Professor  E.  O. 
Jordan,  in  a  protest  published  later  in  the  Journal  of  Public  Health,  says:  "This 
attitude  seems  to  be  based  on  a  fundamental  misconception.  It  does  not  follow  that 
because  the  factor  of  racial  susceptibility  may  be  so  powerful  in  some  instances  as  to 
obscure  completely  the  factor  of  bad  housing,  the  latter  is  not  operative  at  all ....  This 
declaration  seems  to  mean  that  housing  is  practically  negligible,  as  a  public  health  factor .... 
We  do  not  believe  that  this  position  is  tenable."  Professor  Jordan  proceeds  to  cite  facts 
and  authorities  for  his  contention  that  the  sanitary  aspects  of  housing  should  not  be 
minimized. 


62 

rent,  becomes  more  intense.  Nations  must,  therefore,  seek  to 
provide  against  physical  ruin  caused  by  congestion,  an  accom- 
paniment of  progress. 

Crowding  is  found  in  all  the  places  where  wage-earning  men 
and  women  live  and  toil;  in  the  dwelling,  the  workplace,  in  halls 
of  recreation  and  worship,  in  courts  and  prisons. 

I.    CROWDED   DWELLINGS. 

First  of  all  we  must  define  what  we  mean  by  "crowding"  or 
"congestion." 

1.  There  may  be  too  many  people  in  an  urban  district,  and  the 
ground  may  be  covered  with  dwellings  and  shops  to  the  exclusion 
of  open  spaces,  room  for  travel,  traffic,  light,  movement  of  air. 
The  area  taken  as  a  unit  for  a  neighborhood  is  not  easily  fixed; 
approximately  it  is  a  space  found  convenient  for  a  school  dis- 
trict. 

2.  The  block  may  be  crowded  in  two  ways:  by  covering  too 
much  of  the  ground  with  buildings,  and  by  carrying  the  build- 
ings too  high.      Health  requires  that  space  be  left  in  each  block 
for  light,  for  the  free  circulation  of  air,  and  for  the  play  of  little 
children,  even  where  a  small  park  is  not  very  distant.     A  city 
which  makes  provision  only  for  celibates  or   childless   couples 
has  made  its  contribution  to  "race  suicide." 

The  excessive  height  of  the  buildings  endangers  health  in  various 
ways:  it  breaks  down  the  poor  women  who  must  carry  food, 
fuel  and  babies  up  and  down  several  flights  of  stairs.  With  the 
population  of  each  story  noise,  odors,  confusion,  nerve-racking 
friction  are  increased,  and  areas  of  darkness  are  enlarged;  the 
lower  stories  may  be  unfit  for  habitation. 

3.  There  is  crowding  of  rooms  in  each  dwelling.     It  is  true, 
as  Veiller  insists,  that  the  standard  of  so  many  cubic  feet  for 
each  person  is  inaccurate,  unless  we  take  into  account  the  cir- 
culation of  air,  the  entrance  of  germ-killing  light,  and  the  composi- 
tion of  the  domestic  group;  and  yet  the  space  occupied  is  a  vital 
matter. 

Vitiation  of  the  air  in  sleeping  and  living  rooms  is  a  common 
source  of  depression.  Investigations  in  various  cities  have  re- 


63 

vealed  the  fact  that  single  men,  immigrants,  laborers  in  the  great 
industries,  sleep  in  crowded  rooms,  with  windows  nailed  fast  to 
prevent  drafts,  and  in  two  shifts;  the  same  beds  are  used  night 
and  day  by  the  lodgers.1 

Doctor  Oliver  says:  "The  bad  effects  of  overcrowding  and  of 
sleeping  in  ill- ventilated  rooms  are  seen  in  the  readiness  with 
which  fatigue  is  induced  and  in  the  inability  of  workers  thus  im- 
perfectly housed  to  keep  pace  with  their  healthier  comrades  and 
the  increased  speed  at  which  machinery  is  run."2 

In  this  connection  we  have  to  deal  with  the  cheap  lodging 
houses  where  still,  in  spite  of  regulations  and  inspection  of  health 
authorities,  the  miserable  quarters  reek  with  foul  air,  and  the 
slightest  attempts  at  ventilation  by  windows  are  resisted  by  the 
shivering  wanderers  who  are  trying  to  keep  warm. 

Even  in  municipal  lodging  houses  and  police  stations  the  condi- 
tions described  years  ago  by  Wyckoff  (in  "The  Workers")  still 
exist,  to  our  shame  and  injury,  especially  in  midwinter  when 
there  are  many  unemployed,  unmarried  men,  who  flock  to  the 
cities  for  low  satisfactions  and  excitement  in  a  dreary  existence. 

R.  C.  Chapin3  has  sought  to  apply  a  standard  to  the  conditions 
observed  in  our  largest  city.  "The  amount  paid  for  rent  increases 
with  increase  of  income."  "The  average  number  of  rooms  per 
family  increases  with  income."  Poor  folks  have  poor  dwellings, 
which  makes  them  poorer  still.  Fifty- three  per  cent,  of  the  391 
families  studied  reported  dark  rooms.  Not  more  than  one- 
quarter  of  the  families  have  both  room  and  toilet  below  $1100 
income. 

His  standard  of  crowding  (p.  80)  is:  more  than  6  persons  to 
4  rooms,  and  more  than  4  persons  to  3  rooms. 

In  the  lower  income  groups,  overcrowding  is  the  rule.  Over- 
crowding is  more  frequent  among  families  where  the  father  is 
not  the  sole  bread-winner. 

Lodgers  are  more  common  with  the    overcrowded    families; 

1  Miss  Abbott,  authority  in  matters  of  immigration,  declares  rightly  that  no  program  of 
housing  touches  the  origin  of  evil  which  omits  dealing  drastically  with  this  crowding  of 
lodgers. 

2  "Diseases  of  Occupation."  p.  2. 

1  1909.     "The    Standard    of   Living   among    Workingmen's   Families   in    New    York 
City,"  p.  75ff. 


64 

29  per  cent,  of  318  families  with  income  between  $600  and  $1100 
have  lodgers. 

Testimony  of  the  Evils  of  Overcrowding.1 

In  the  endeavor  to  reduce  rent  among  the  very  poor,  they  pack 
themselves  into  a  limited  space  at  cost  of  vitality,  directly  and 
indirectly.  Even  thrifty  people,  if  ignorant,  who  are  not  eco- 
nomically compelled  to  accept  injurious  conditions,  will  do  so 
in  order  to  have  more  to  spend  in  luxuries  or  to  save. 

"The  medical  officer  of  the  London  County  Council  has  shown 
that  the  death  rate  steadily  increases  with  the  density  of  popula- 
tion."2 

The  Secretary  of  the  New  York  Tenement  House  Commission 
of  1894  (Report,  p.  12)  says  that  overcrowding  has  evil  effects 
of  various  kinds,  for  example:  "Keeping  children  up  and  out  of 
doors  until  midnight  in  warm  weather,  because  rooms  are  unen- 
durable; making  cleanliness  of  house  and  street  difficult;  filling 
the  air  with  unwholesome  emanations  and  foul  odors  of  every 
kind;  producing  a  state  of  nervous  tension  and  interfering  with 
the  separateness  of  home  life;  leading  to  a  promiscuous  mixing 
of  all  ages  and  sexes  in  a  single  room,  thus  breaking  down  the 
barriers  of  modesty  and  conducing  to  the  corruption  of  the  young, 
and  occasionally  to  revolting  crimes."  The  Royal  Commission 
of  1884,  in  London,  gathered  a  wealth  of  testimony  on  the  evils 
of  overcrowding.3  In  England  the  school  board  visitors,  clergy- 
men, charity  agents,  and  others  know  far  more  intelligently  and 
intimately  than  similar  workers  in  this  country  the  lives  of  the 
poor  in  their  homes.  From  their  testimony  it  was  gathered  that 
immorality,  sexuality,  drunkenness,  pauperism,  and  many  forms 
of  debauchery  were  caused  in  some  instances,  in  others  abetted, 
by  the  indecent  overcrowding  which  existed.  The  testimony 
further  showed  most  distressing  physical  results  due  to  over- 
crowding. High  death  rates,  a  pitiful  increase  in  infant  mor- 
tality, terrible  suffering  among  little  children;  scrofula  and  con- 
genital diseases;  ophthalmia,  due  to  dark,  ill- ventilated,  over- 

1  "Tenement  Conditions  in  Chicago,"  p.  51. 

8  Bowmaker,  "Housing  of  the  Working  Classes,"  p.  15. 

»  Report,  "Housing  of  Working  Classes,"  Vol.  I,  pp.  13-14. 


65 

crowded  rooms;  sheer  exhaustion  and  inability  to  work;  encour- 
agement of  infectious  diseases,  reducing  physical  stamina,  and 
thus  producing  consumption  and  diseases  arising  from  general 
debility,  were  some  of  the  evils  of  overcrowding. 

When  the  dwelling  must  perform  the  double  function  of  habita- 
tion and  workshop,  the  evils  are  increased.  The  rooms  are  occu- 
pied day  and  night,  without  intervals  for  ventilation;  particles 
of  dust  are  torn  or  worn  off  the  materials  of  manufacture  and  float 
without  cessation  into  the  irritated  and  sensitive  lungs ;  the  fires 
of  the  ironing  apparatus  make  the  temperature  feverish  and  the 
nauseous  vapors  of  the  washing  infect  the  atmosphere  with  their 
sickening  odors,  so  that  the  very  food  becomes  loathsome;  the 
clatter  and  jar  of  the  work  keeps  the  nerves  tense  and  strained; 
the  rest  needed  by  the  infants  and  younger  children  is  destroyed 
and  the  assimilation  of  food  is  disturbed. 

And  yet  if  we  seek  for  exact  scientific  proof  of  these  impressions 
which  all  social  workers  have  received  from  their  constant  con- 
tacts with  the  urban  poor,  we  find  it  difficult  to  discover  satis- 
factory evidence.  Here  is  a  field  for  accurate  investigation  yet 
to  be  explored  by  competent  persons.1  Professor  Winslow  says: 
"In  one  of  the  most  careful  of  such  studies,  for  example  (L.  M. 
Bristol:  The  Relation  of  Congestion  of  Population  to  Mortality 
in  Boston, 'New  Boston,  1,201)  results  were  obtained  which  indi- 
cate a  direct  relation  between  overcrowding  and  a  high  death 
rate,  the  highest  comparative  mortality,  over  160,  occurring  in 
districts  with  12  persons  per  dwelling,  and  the  lowest,  under  90, 
with  7  persons  per  dwelling.  In  the  January,  1911,  Monthly 
Bulletin  of  the  New  York  City  Board  of  Health,  interesting  sta- 
tistics for  infant  mortality  in  certain  blocks  were  given  which 
showed  a  rate  of  50.8  deaths  per  1,000  births  in  a  poor  residential 
district  with  216.9  persons  to  the  acre,  against  318.8  deaths 
per  1,000  births  in  a  negro  quarter  with  1051.1  persons  to  the 
acre."  Such  facts  seem  to  be  conclusive;  yet  we  must  not  rashly 
stop  with  them.  In  the  same  New  York  document  we  find  that 
in  the  most  crowded  district  studied,  with  2471.9  persons  to  the 

1  Prof.  C.-E.  A.  Winslow,  "Proceedings  of  American  Association  for  Study  and  Pre- 
vention of  Infant  Mortality,"  1911,  p.  149. 


66 

acre,  there  were  only  156.4  deaths  per  1000  births.  In  Chicago, 
in  the  old  Seventh  Ward,  the  death  rate  was  only  n  .99  per  1000, 
while  in  the  neighboring  ward  it  was  45 . 9  per  cent,  higher.  The 
sanitary  conditions  in  both  wards  are  equally  bad,  but  where  the 
Jews  lived  the  rate  was  lowest  ("Tenement  Conditions  in  Chicago," 
p.  158).  Racial  tenacity  of  life,  sanitary  living,  tender  care  of 
infants  and  many  other  factors  enter  into  the  problem  and  must 
be  separately  weighed  before  really  scientific  conclusions  can  be 
reached. 

It  gives  some  of  us  a  mental  wrench  to  accept  the  new  theories 
of  ventilation;  but  we  must  revise  our  antiquated  notions  on  the 
subject.  We  can  no  longer  accept  the  number  of  cubic  feet  of 
space  in  a  dwelling  room  as  a  sufficient  standard.  We  must  take 
into  account  the  windows,  the  movement  of  air,  the  quality  of 
the  surrounding  atmosphere,  the  relative  moisture,  the  tempera- 
ture of  the  house. 

It  should  not  surprise  us  to  find  in  future  municipal  building 
codes  requirements  for  electric  fans,  exhaust  pipes,  apparatus  for 
control  of  moisture  and  temperature,  as  well  as  window  and  floor 
space.1 

n.  IN  THE  WORKSHOP. 

In  the  workplace  we  encounter  the  same  principles  of  hygiene, 
the  same  complexity  of  causes,  the  same  difficulty  of 'giving  due 
weight  to  the  single  factor  of  crowding,  and  so  it  is  needless  to  repeat 
what  has  been  said  in  connection  with  depressing  conditions  at 
home. 

We  may,  however,  call  special  attention  to  the  increased  dan- 
ger of  external  injuries,  so-called  " accidents"  of  industry,  which 
arise  from  moving  machinery  and  from  the  collision  of  persons 
working  in  a  narrow  space,  near  traps,  elevators,  stairways. 

In  the  cramped  quarters  where  sewing  women  and  men  manu- 
facture garments  at  furious  pace,  in  stifling  and  ill-lighted  halls, 
for  long  hours,  the  immunity  to  tuberculosis  and  pneumonia  is 
often  lost,  and  the  moments  of  exposure  are  multiplied.  Crowd- 
ing, must,  therefore,  be  considered  as  a  cooperating  cause  in  con- 

1  Lawrence  Veiller,  "Room  Overcrowding  and  the  Lodger  Evil."  National  Housing 
Publication,  No.  18. 


67 

nection  with  related  causes,  for  the  shortening  of  life  and  the  de- 
preciation of  industrial  efficiency. 

III,  IN  HALLS   OF  RECREATION. 

The  public  halls  in  which,  especially  in  winter  time  in  our  north- 
ern climate,  millions  of  working  people  seek  their  recreation, 
amusement,  fellowship  and  culture,  are  frequently  cultivating 
tubes  of  colonies  of  deadly  microbes,  which  turn  happy  gaiety 
into  fever  and  sadness.  The  sudden  popularity  of  the  moving 
picture  shows  has  thrust  upon  health  authorities  many  new  and 
vexing  problems.  The  multitudes  have  no  hygienic  standards; 
so  long  as  they  are  not  in  a  freezing  draft  of  chilling  air,  or  posi- 
tively boiling  in  a  steaming  and  superheated  atmosphere,  they 
make  no  complaint.  Poor,  ignornat  mob,  they  need  to  be  pro- 
tected against  themselves!  Fortunately,  the  people  are  capable 
of  understanding  instruction  when  backed  by  professional  author- 
ity ;  and  the  picture  show  itself  has  become  a  medium  of  popular- 
izing the  science  which  saves  life. 

IV.  IN  PUBLIC  INSTITUTIONS. 

Workmen  furnish  a  certain  contingent  to  the  population  of 
our  city  lockups  and  county  jails;  they  serve  on  juries  in  vast 
numbers;  and  in  their  search  for  employment  many  an  honest 
country  lad  meets  his  physical  and  moral  doom  in  a  cheap  lodging 
house. 

Any  one  who  has  studied  the  ordinary  city  lockup  and  county 
jail  devoutly  wishes  that  each  judge,  sheriff,  and  chief  of  police 
could  be  made  to  spend  a  night  once  a  month  in  the  vile  dens 
which  our  civilization  tolerates.  And  if  preachers  and  editors 
could  be  made  to  take  their  turn  at  the  same  experience,  pulpits 
and  newspapers  would  never  cease  to  raise  an  outcry  against 
the  shameful  condition. 

I  have  been  searching  medical  and  public  health  journals 
for  protests  against  this  infamy  and  menace — in  vain;  perhaps 
some  one  with  a  sharper  eye  will  call  attention  to  articles  which 
I  have  not  been  able  to  discover,  and  I  would  be  grateful  for  refer- 
ences. 


68 

It  is  useless  for  us  laymen  to  protest,  as  we  have1  done  for  thirty 
years.  Judges,  lawyers,  police,  all  turn  a  deaf  ear  to  us;  they 
listen  only  to  professional  experts. 

We  have  permitted  the  architects,  steel-construction  people, 
and  authorities  to  continue  building  for  these  places  of  detention 
a  type  of  habitation  which  is  condemned  for  sleeping  rooms, 
offices,  kitchens  and  even  for  hen-coops  and  cow-stables.  The 
"Bull  pen"  is  a  costly  steel  cage,  constructed  in  the  center  of  a 
vast  chamber,  and  the  cage  is  surrounded  by  a  corridor  where 
innocent  and  guilty  are  forced  to  associate  in  a  common  hall, 
and  where  the  most  depraved  and  satanic  character  is  hero  and 
ruler.  The  air  is  loaded  with  corruption,  with  infection,  with 
curses,  with  obscurity.  The  light  of  heaven  fades  away  in  its 
passage  from  the  window  to  the  interior  of  the  cell,  and  I  have 
seen  corridors  which  had  no  external  window  whatever. 

When  we  consider  how  readily  many  policemen  arrest  men 
who  are  not  criminal  and  who  are  at  once  discharged  by  the  court 
from  want  of  evidence;  when  we  remember  that  any  one  of  us 
may  be  thrust  into  one  of  these  black  holes  at  midnight  in  a  strange 
city,  especially  if  we  are  poor  and  unknown ;  when  we  consider  that 
those  thus  subjected  to  physical  and  moral  contamination  go  out 
in  all  directions  to  infect  others;  the  apathy  of  the  medical  pro- 
fession is  discouraging  beyond  expression. 

Crowding  in  these  vile  dungeons  often  reaches  the  point  of 
purgatory.  There  is  no  privacy.  The  clean  young  fellow  who 
is  arrested  on  suspicion,  the  honest  mechanic  who  is  intoxicated, 
the  mere  accidental  witness  may  be  compelled  to  share  a  lousy 
bed  or  dirty  board  with  some  unspeakably  offensive  degenerate 
to  whom  this  perdition  is  joy  and  light,  as  compared  with  the 
barrel  under  a  sidewalk  when  the  thermometer  is  at  zero. 

Why  should  we  not  provide  at  least  a  narrow,  though  clean  and 
ventilated  cell  for  every  person  arrested?  Why  should  we  not 
require  that  that  cell  have  at  least  a  bit  of  window  opening  to 
the  sky,  the  sun  and  the  pure  outside  air?  Why  should  not  that 
cell  be  walled  with  concrete  and  the  surface  finished  so  it  could 
be  washed  clean  every  day  or  disinfected  if  required? 

1  Report  on  jails,  by  the  writer,  American  Prison  Association,  1907. 


69 

If  any  one  who  either  has  not  seen  these  places,  or  looked 
at  them  unmoved  because  he  had  no  standard,  thinks  I  have  used 
strong  language,  I  can  only  retort  that  I  would  have  used  more 
forcible  and  adequate  epithets  if  I  could  find  them. 

V.      HINTS  FOR  AMELIORATION. 

This  part  of  the  subject  is  reserved  for  others;  but  I  may  be 
permitted  to  indicate  a  few  lines  of  investigation: 

1.  The  periodical  inspection  of  workmen,  by  authority,  in  all 
occupations  to  discover  defects  and  incipient  disease. 

2.  The  making  of  records  of  the  occupational  history  of  every 
man  who  comes  under  medical  care. 

3.  The  construction  of  medical  standards  of  judgment  on  all 
the  points  here  considered,  as  a  guide  to  public  opinion,  legisla- 
tion and  administration. 

4.  Cooperation  of  all  social  workers,  under  medical  direction, 
to  secure  the  embodiment  of  advanced  standards  in  building 
codes,  in  protective  legislation,  and  in  sanitary  regulations  of 
shops,  dwellings  and  public  buildings. 

It  has  been  shown  that  no  one  physical  cause  of  disease  can  be 
isolated  from  the  complex  of  depressing  conditions;  it  needs 
also  to  be  pointed  out  that  the  social  causes  are  even  now  complex 
and  entangled.  Many  people  crowd  their  dwellings  and  take  in 
lodgers  because  they  are  wretchedly  poor.  If  society  requires 
a  minimum  space  for  residence,  it  must  also  guarantee  a  minimum 
income  to  pay  the  rent;  and  this  calls  for  poor  relief,  or  for  mini- 
mum wage,  or  for  social  insurance;  and  thus  by  studying  closely 
one  evil  we  launch  upon  a  voyage  of  exploration  in  which  we  re- 
quire the  guidance  of  all  the  sciences  at  once.  Thus  also  we 
realize  how,  in  order  to  "lift  up  the  manhood  of  the  poor"  all 
men  of  light  and  good  will  must  cooperate. 


HOW  FOODS  AND  DRUGS  CAN  MENACE. 


By  WiNKiBtD  SCOTT  HAW,,  Ph.D.,  M.D.,  Professor  of  Physiology,  Northwestern  University 
Medical  School,  Chicago. 

There  is  probably  no  field  of  personal  and  domestic  hygiene 
in  which  the  general  practitioner  of  medicine  finds  more  frequent 
necessity  for  instruction  and  counsel  than  that  which  concerns 
the  relation  of  his  patients  to  foods  and  drugs.  This  is  true  not 
only  among  his  families  on  the  boulevards  and  avenues,  but  also 
among  those  who  occupy  the  narrow  back  streets,  namely,  the 
wage-earning  operatives  in  factories  and  shops.  As  a  matter  of 
fact,  the  relation  of  these  wage-earners  to  foods  and  drugs  may 
contain  an  even  greater  menace  to  their  health  because  in  the  case 
of  the  wage-earner  we  add  to  ignorance  of  the  general  principles 
of  hygiene  the  economic  factor. 

So  far  as  food  concerns  the  wage-earner  the  menace  is  practically 
confined  to  two  factors,  namely,  lack  of  information  and  lack  of 
funds.  These  factors  may  operate  singly  or  conjointly,  but  in 
either  case  they  seriously  complicate  the  condition. 

In  so  far  as  drugs  concern  the  wage-earner,  we  deal  first  with 
ignorance,  then  with  several  other  factors  such  as  example,  de- 
sire, lack  of  will  power,  etc. 

FOODS. 

(l)    UNWISE  SELECTION  OF  FOODS. 

(j)  Due  to  Lack  of  Information.  —  The  writer  has  frequently 
passed  by  a  group  of  wage-earners  at  lunch  and  has  incidentally 
noted  the  character  of  the  average  wage-earner's  menu.  For 
drink  he  will  have  either  coffee  or  beer.  There  is  certainly  no 
objection  to  the  former.  If  he  adds  a  quart  of  beer  instead  of 
the  coffee,  it  is  probably  due  to  the  fact  that  his  father  before  him 
used  beer  with  his  lunch,  and  the  man  in  question  has  inherited 
from  his  ancestors  the  dogma  that:  "Beer  is  liquid  bread."  The 
lunch  is  not  supposed  to  be  complete  without  one  or  two  cold 
fried  pork  chops  or  lamb  chops  and  a  piece  of  pie  or  cake  or  both, 
also  some  pickles. 


Very  frequently  the  writer  has  stepped  into  a  lunch  room  for 
a  bowl  of  "half-and-half"  milk  and  cream  with  bread  and  has 
noticed  incidentally  a  young  wage-earner  on  his  right  ordering 
pie  "a  la  mode"  and  coffee,  while  perhaps  the  young  man  on  his 
left  is  regaling  himself  for  his  four  or  five  hours  of  afternoon 
work  with  strawberry  shortcake  and  coffee. 

Finally,  it  is  a  common  thing  to  observe  the  wife  of  a  wage- 
earner  in  the  market  selecting  foods  of  low  food  value,  perhaps 
out  of  season  and  high-priced,  selecting  cuts  of  meat  that  are  the 
most  expensive  and  no  more  nourishing,  the  selection  being  deter- 
mined either  by  the  fact  that  the  woman  knew  how  to  cook  the 
expensive  mutton  chop  or  steak,  but  did  not  know  how  to  cook 
the  very  much  less  expensive  "boiling  or  stewing  cut."  The 
children  from  these  families  run  bare-headed  across  the  street  to 
the  delicatessen,  perhaps  just  before  or  actually  during  the  meal 
to  buy  some  expensive  material  of  doubtful  nutritive  value  for 
dessert;  and,  finally,  the  baby  in  that  same  family  may  be  given 
grossly  improper  foods,  not  at  all  adapted  to  its  age  and  digestive 
powers,  because  the  mother  is  lacking  in  information  regarding 
just  what  the  baby's  needs  are.  Children  of  school  age  from  these 
families  spend  enough  pennies  each  day  for  cheap  candy,  gum, 
ice  cream  cones,  and  the  like,  to  buy  a  loaf  of  bread,  a  pint  of  milk 
or  two  fresh  eggs.  All  of  this  unfortunate  choice  of  foods  which 
involves  not  only  waste  of  meagre  funds,  and  provides  food  of 
doubtful  value  and  perhaps  actually  harmful,  is  due  to  lack  of 
information  on  the  part  of  those  who  select  the  foods. 

The  well-informed  mother  of  such  a  family  will  provide  for  her 
wage-earning  husband  and  son  lunches  of  bread,  meat  and  coffee, 
perhaps  a  hard-boiled  egg  or  two  may  be  added  to  the  lunch. 
If  the  coffee  can  be  kept  warm  or  can  be  made  warm  at  lunch 
time,  in  the  cold  season  of  the  year  particularly,  it  affords  the 
worker  his  warm  lunch,  and  the  meat  sandwiches  afford  him 
proper  and  adequate  nourishment  for  his  afternoon  work. 

The  well-informed  man  understands  that  a  quart  of  beer, 
though  costing  as  much  as  the  loaf  of  bread,  contains  no  more 
nourishment  than  one  mouthful  of  bread.  He  will  therefore  not 
spend  his  nickel  for  that  which  is  not  bread.  In  a  similar  way 


72 

he  would  reason  that  coffee  and  pie  or  other  rich  dessert  make  a 
very  inadequate  and  unsatisfactory  lunch  for  a  man  who  must 
do  four  or  five  hours  of  hard  work.  The  same  fifteen  cents  which 
he  would  pay  for  such  a  lunch,  if  expended  for  wisely 
selected  foods,  would  pay  for  a  lunch  much  more  easily  digested 
and  containing  three  or  five  times  as  much  nourishment. 

(2)  Due  to  Financial  Limitation. — The  unwise  selection  of  foods 
may  be  due  more  to  financial  limitations  than  to  lack  of  informa- 
tion. For  example,  the  mother  may  know  that  the  welfare  of 
her  baby  depends  upon  its  getting  good  milk,  but  certified  milk, 
the  best  food  for  her  baby,  next  to  mother's  milk,  would  cost  fif- 
teen cents  a  quart  and  she  may  not  be  able  to  afford  that  amount. 

The  young  girl  who  is  receiving  a  starvation  wage  of  only  six 
dollars  a  week  and  is  trying  to  eke  out  that  meagre  sum  to  make 
it  cover  rent,  clothing,  board,  laundry,  carfare  and  postage  on 
her  letters  home,  finds  that  she  cannot  spend  more  than  twenty- 
five  cents  a  day  for  food  if  she  is  to  dress  respectably.  That 
means  that  at  least  two  of  her  meals  must  be  cold  lunches  in  her 
room  and  must  be  reduced  to  ten  cents  for  the  two  meals,  while 
her  third  meal,  and  the  only  square  meal  of  the  day,  is  a  fifteen- 
cent  one  taken  at  a  woman's  lunch  club  down  town.  She  knows 
that  she  is  illy  nourished  and  that  she  needs  more  eggs,  vegetables 
and  fruit  if  she  is  to  keep  her  girlhood  vigor  and  freshness  of  color, 
but  the  poor  child  simply  hasn't  the  price,  so  she  lives  on  crackers 
and  cheese,  dry  bread  and  milk,  good  enough  so  far  as  it  goes, 
but  so  lacking  in  variety  that  by  the  time  she  has  had  the  same 
thing  three  or  four  hundred  times  she  loses  appetite  and  would 
rather  go  to  bed  without  any  supper  in  order  to  have  a  double 
portion  of  meat-stew  at  the  club  the  next  day. 

(ll)    IMPROPER   CARE   OF   FOODS. 

(/)  Due  to  Lack  of  Knowledge. — In  a  large  proportion  of  the 
homes  of  wage-earners  the  improper  care  of  foods  may  serve  di- 
rectly or  indirectly  as  a  menace  to  health.  Partially  used  food 
may  be  left  upon  the  kitchen  table  fron  one  meal  to  the  next, 
or  if  cleared  from  the  table  it  may  be  carelessly  tucked  into  a 
kitchen  cupboard  where  fermentative  processes  or  even  putrefac- 


73 

live  processes  may  begin  and  get  well  under  headway  before  the 
food  is  thrown  away  or  consumed.  The  flies  from  back  alleys 
and  barns — or  worse  yet — from  neighboring  sick  rooms,  have 
free  access  to  this  food  and  may  deposit  a  trail  of  disease  germs 
upon  it.  The  milk  for  the  baby  stands  open  on  the  kitchen  table 
and  may  be  equally  contaminated,  but  the  innocent  defenseless 
child  has  no  other  food  provided  until  the  following  day,  though 
the  bacterial  count  may  mount  into  the  millions  during  an  August 
or  September  day  and  night. 

All  of  these  unfortunate  things  can  happen  in  a  family  purely 
as  a  result  of  ignorance. 

(2)  Due  to  Lack  of  Facilities. — Even  if  the  housewife  knows 
better  than  to  leave  food  exposed  in  this  way  to  heat,  desiccation 
and  contamination,  she  may  lack  the  facilities  for  proper  care  of 
it.  She  has  no  refrigerator  and  cannot  keep  her  baby's  milk 
cold;  she  has  no  screens  for  doors  and  windows  and  therefore 
cannot  keep  the  flies  out  of  the  house;  she  has  no  stone  jar  or  tin 
can  for  a  bread  box  and  therefore  the  bread  dries  or  moulds. 
Women  subjected  to  such  domestic  conditions  are  very  likely  to 
throw  away  unused  portions  of  food  because  of  lack  of  facili- 
ties. Waste,  therefore,  in  such  homes  becomes  a  serious  compli- 
cating factor.  As  a  matter  of  fact,  in  many  homes  there  is  enough 
food  wasted  every  six  months  to  pay  for  a  refrigerator  and  keep 
it  stocked  with  ice;  to  pay  for  screens  for  windows  and  doors, 
and  for  other  facilities  necessary  properly  to  care  for  the  food, 
so  that  the  half -loaf  and  half -roast  could  all  be  used  up  and  not 
consigned  to  the  garbage  can. 

(ill)  IMPROPER  PREPARATION  OF  FOODS. 

(j)  Due  to  Lack  of  Knowledge. — Many  a  housewife,  through 
lack  of  knowledge,  fails  properly  to  prepare  foods  and  therefore 
may  serve  to  her  family  nourishment  which  may  carry  a  menace 
to  their  health,  either  in  foods  that  are  difficult  of  digestion,  or 
in  foods  that  may  have  become  contaminated  in  the  market  or  in 
the  kitchen.  Many  of  the  foods  are  handled  carelessly  in  the 
markets  and  are  not  protected  from  flies,  either  in  the  markets 
or  in  transit  to  the  homes.  Many  of  the  foods  therefore  require 


74 

very  careful  washing  in  the  kitchen  before  they  are  cooked.  The 
bacteria  of  fermentation  and  putrefaction  are  killed  by  adequate 
cooking.  It  is  also  true  that  as  a  rule  these  bacteria  are  killed 
in  the  stomach  by  the  hydrochloric  acid  of  the  gastric  juice, 
but  this  latter  is  not  always  the  case  and  occasionally  an  individual 
may  be  temporarily  afflicted  with  hypochlorhydria.  In  such  a 
case  the  ingestion  of  foods  contaminated  with  these  bacteria 
superadding  them  to  those  already  inhabiting  the  alimentary 
tract  may  start  and  probably  would  start  a  furious  bacterial 
activity  in  that  tract  that  would  seriously  complicate  the  condi- 
tion of  the  individual.  In  the  preparation  of  foods  every  house- 
wife should  know  the  importance  of  properly  cleansing  the  ma- 
terial before  cooking,  and  then  of  properly  cooking  the  material 
in  question.  Adequate  knowledge  will  prevent  waste  of  valuable 
materials.  A  quart  of  milk  that  may  have  become  sour  need 
not  be  thrown  away  and  it  ought  not  to  be  eaten  without  proper 
preparation.  The  efficient  housewife  neutralizes  the  acidity  with 
cooking  soda  and  uses  the  milk  in  any  one  of  a  hundred  ways  to 
make  a  wholesome  dish  for  the  evening  meal.  A  delicious  custard, 
for  example,  might  be  made  that  would  be  not  only  easily  digested 
but  wholesome  and  could  afford  nearly  the  whole  meal  for  the 
younger  children  of  the  family,  from  one  to  five  or  seven  years 
of  age. 

The  dissemination  of  information  among  the  home-makers  of 
the  wage-earning  class  regarding  the  selection,  care  and  prepara- 
tion of  foods  is  a  matter  of  the  greatest  importance  and  one  which 
would  contribute  greatly  to  their  well-being. 

(2)  Due  to  Financial  Limitations. — A  certain  amount  of  the 
difficulty  in  the  preparation  of  foods  is  due  to  fuel  economy  and 
inadequate  cooking  resulting  therefrom.  It  is  very  common  to 
see  cereals  that  should  be  cooked  an  hour  or  more,  cooked  only 
five  or  ten  minutes.  This  saves  fuel,  but  what  the  stove  fails  to 
do  the  digestive  organs  must  accomplish,  namely,  the  breaking  up 
of  the  starch  grains  and  the  digestion  of  the  starch;  the  first  part 
of  this  work  should  be  accomplished  in  the  preparation  while  the 
second  alone  is  the  proper  work  of  the  digestive  system. 


75 
DRUGS. 

(l)    THE   PATENT  MEDICINE   HABIT. 

(i)  Due  to  Ignorance. — A  vast  preponderance  of  the  use  of 
patent  medicine  is  found  among  farmers  and  the  wage-earning 
class  of  the  big  cities.  A  generation  ago  the  use  of  patent  medi- 
cines was  more  general,  but  as  the  decades  go  by,  their  use  becomes 
more  and  more  limited  to  those  who  are  less  instructed  regarding 
the  use  of  drugs,  and  who  are  more  accessible  to  the  advertiser. 
The  cheap  journals  and  weeklies  are  read  freely  by  these  people 
and  they  are  strongly  influenced  by  the  advertisements  which 
make  up  no  small  part  of  their  printed  matter.  The  vender  of 
panaceas  finds  in  the  family  of  the  wage-earning  man  the  freest 
buyers  of  his  nostrums.  They  read  the  printed  matter  on  the 
label  and  the  accompanying  pamphlet  with  the  same  trustful 
credulity  that  they  read  the  columns  of  the  weekly  county  paper, 
so  they  continue  to  buy  "sure  cures"  for  rheumatism,  neuralgia, 
dyspepsia,  "liver  troubles,"  "kidney  troubles,"  "nervous 
troubles,"  etc. 

Until  the  enactment  of  the  food  and  drugs  act,  it  was  almost 
the  universal  custom  of  patent  medicine  makers  to  combine  in 
their  prescription  besides  an  active  drug — which  might  or  might 
not  have  the  desired  action — a  strong  narcotic :  alcohol,  morphine, 
cocaine,  chloral  hydrate,  etc.  In  reality  it  was  the  influence  of 
the  narcotic  in  these  patent  medicines  that  insured  the  more  or 
less  continued  use  of  them  once  the  "remedy"  was  tested. 

In  ignorance  and  false  economy  the  wage-earner  called  the  prac- 
titioner of  medicine  only  in  cases  of  desperate,  acute  and  imme- 
diate need.  Sub-acute  and  chronic  conditions  he  attempted  to 
treat  at  home  through  the  help  of  these  much  vaunted  remedies. 

One  of  the  most  serious  cases  of  hob-nailed  liver  that  the  writer 
has  ever  seen  was  a  victim  of  Peruna  in  the  days  when  Peruna 
contained  at  least  40  per  cent,  of  alcohol;  the  case  was  that  of  a 
woman-^— a  temperance  worker  of  considerable  prominence.  She 
had  taken  Peruna  for  a  number  of  years,  in  ever  increasing  doses  ; 
she  was  a  chronic  alcoholic;  but  due  to  her  work  for  temperance, 
her  symptoms  were  wholly  misunderstood  by  her  family  and 
friends.  She  finally  died  of  chronic  alcoholism,  yet  no  drop  of 


76 

alcoholic  beverage  with  the  exception  of  Peruna  ever  passed  her 
lips.  Post-mortem  examination  revealed  the  real  cause  of  her 
death,  which  had  been  obscure  and  which  had  puzzled  the  medical 
staff  of  one  of  our  largest  hospitals  in  which  she  spent  the  last  few 
days  of  her  life.  This  was  a  plain  case  of  ignorance  which  led 
to  the  patent  medicine  habit  being  established  in  the  first  place 
and  continued  to  the  end. 

(2)  Due  to  Example. — Many  a  patent  medicine  victim  falls  into 
the  habit  through  the  example  or  advice  of  a  neighbor.  It  is 
quite  probable  that  this  accounts  for  the  beginning  of  the  habit 
in  a  majority  of  the  cases.  The  kind  of  a  man  who  takes  Smith's 
vinegar  bitters  for  his  stomach  or  Jones '  sarsaparilla  for  his  blood, 
is  the  kind  of  a  man  who  talks  to  his  neighbors  about  his  ail- 
ments, describing  his  symptoms  in  detail.  The  ignorant 
young  neighbor  who  has  not  yet  acquired  any  series  of 
symptoms  peculiarly  his  own,  listens  with  bated  breath 
to  the  recountal  of  his  old,  experienced  neighbor.  He 
shows  interest  in  the  case  and  the  "cure."  His  old  neighbor  gets 
the  pamphlet  that  came  with  the  "remedy."  The  young  man 
takes  it  home  and  reads  it,  and  as  he  reads  he  fancies  that  he  him- 
self has  noticed  those  same  symptoms.  He  has  noticed  that  he 
experiences  a  loss  of  appetite  after  each  meal;  that  he  experiences 
a  disinclination  to  get  up  in  the  morning  and  various  other  omi- 
nous symptoms,  so  he  tries  his  first  bottle.  The  chances  are  that  it 
is  the  first  of  a  dozen  bottles — is  the  beginning  of  a  lifetime 
habit  of  doping  himself  and  his  family. 

(n)    DRUG   AND   DRINK  ADDICTIONS. 

(i)  Caused  by  Example. — The  influence  of  example  in  starting 
the  patent  medicine  habit  has  just  been  set  forth.  In  no  small 
proportion  of  the  cases  the  patent  medicine  habit  in  general  is  the 
forerunner  of  and  the  cause  of  a  special  drug  addition  that  may 
really  ruin  the  life  of  the  individual.  This  is  particularly  the 
case  when  medicine  that  contains  morphin,  cocain  or  chloral 
has  been  used.  The  victim  finds  out  that  the  particular  con- 
stituent of  the  remedy  which  has  the  sought-for  quieting  effect 
and  makes  him  oblivious  to  his  troubles  both  physical  and  mental, 


77 

is  a  substance  which  he  can  buy  separately  at  the  drug  store,  so 
he  begins  his  downward  course  as  a  morphin  or  cocain  fiend, 
using  all  sorts  of  devices  to  get  the  drug  from  the  "honest  drug- 
gist." 

(2)  Caused  by  Patent  Medicine.  Habit. — Patent  medicines  which 
contain  twenty-five  per  cent,  or  more  of  alcohol  are  very  likely 
to  cause  the  victim  to    become  eventually  a  chronic  alcoholic, 
if  he   discovers  that  the    constituent  whose  special  action  he 
craves  is  alcohol. 

(3)  Caused  by  Physician's  Prescription  Misused. — Many  a  case 
of  drug  addiction,  yes  of  drink  addiction  too,  has  been  caused  by 
the  misuse  of  a  physician's  prescription.     There  are  certain  ag- 
gravated acute  cases  where  the  physician  prescribes  morphin  or 
brandy  to  alleviate  the  condition  with  no  thought  that  he  may 
be  handing  to  his  patient  a  dangerous  weapon,  which  the  patient 
may  later  use  suicidally,  tho  without  suicidal  intent.     While  the 
prescription  is  left  at  the  drug  store  the  patient  has  the  number 
of  the  prescription  on  the  box  or  bottle  and  returns  repeatedly  to 
have  it  refilled;  this  may  go  on  for  a  month  or  a  year.     He  may 
get  a  copy  of  the  prescription  from  the  druggist  and  move  to 
some  other  city  or  state  and  continue  to  have  this  prescription 
refilled  to  the  end  of  the  chapter.     Years  after  the  physician  has 
forgotten  the  patient,  his  prescription  is  being  refilled  by  a  drug- 
gist a  thousand  miles  away.     The  victim  of  the  drug  addiction 
may  have  had  his  life  ruined.     Physicians  are  in  these  days 
conscientiously  careful  not  to  give  prescriptions  that  contain  any 
appreciable  amount  of  narcotic.     If  it  is  necessary  to  administer 
a  narcotic  drug  in  an  aggravated  or  acute  case  the  physician  ad- 
ministers it  personally  or  directs  the  nurse  to  do  so  and  the  patient 
does  not  know  what  he  receives  and  if  he  should  later  ask  what  it 
was  that  gave  him  such  complete  relief,  he  is  given  an  evasive 
answer.     The  writer  personally  knows  of  a  case  where  a  cocain 
solution  was  used  to  allay  irritation  in  the  nasal  mucous  mem- 
brane.    The  patient  was  given  a  prescription.     He  used  the  douche 
in  considerable  excess,  was  keen  enough  to  know  that  it  was  the 
cocain  in  it  which  caused  his  pleasurable  sensations,  and  began 
the  use  of  the  drug  as  a  confirmed  cocain  fiend.     Too  much  care 


78 

cannot  be  exercised  by  practitioners  in  the  use  of  narcotics.  No 
prescription  for  morphin  or  cocain  should  ever  be  put  into  the 
hands  of  the  patient.  If  the  case  is  sufficiently  serious  to  require 
these  drugs  the  physician  or  nurse  should  personally  administer 
them  and  under  no  conditions  should  the  patient  be  told  what 
he  is  getting. 

(4)  Caused  by  Food  Accessories. — (a)  Tea  and  Coffee  Addiction: 
While  tea  and  coffee  in  moderate  strength  may  be  used  a  lifetime 
in  moderation  by  most  people,  it  sometimes  happens  that  an  in- 
dividual of  nervous  temperament  discovers  that  these  beverages 
afford  a  noticeable  stimulation  which  is  pleasing  and  which  they 
convince  themselves  to  be  actually  advantageous.  While  oc- 
casional caffein  stimulation  may  be  advantageous,  frequent  ex- 
treme caffein  stimulation  is  distinctly  disadvantageous,  but  the 
victim  of  the  caffein  habit  step  by  step  gets  drawn  deeper  into 
the  mire  of  addiction  until  he  becomes  a  real  tea  or  coffee  fiend. 
The  writer  has  known  women  who  had  tea  for  breakfast,  dinner 
and  supper,  two  or  three  cups  at  each  meal;  and  then  finally  reached 
the  point  of  resorting  to  tea  in  the  afternoon  or  evening  to  keep 
them  awake  and  to  keep  them  going.  The  writer  has  known  men 
and  women  so  addicted  to  coffee  that  they  used  from  ten  to  fif- 
teen cups  of  strong  coffee  a  day,  thus  almost  continuously 
whipping  their  tired  nerves  with  the  caffein  lash.  Such  gross  ex- 
cess in  the  use  of  tea  or  coffee  must  be  classified  among  the  drug 
addictions,  and  while  they  are  not  by  any  means  so  serious  as 
morphin,  cocain  or  alcohol  addictions,  they  are  nevertheless 
sufficiently  serious  to  merit  attention  in  this  connection.  The  ex- 
cessive use  of  these  stimulants  seriously  menaces  the  general 
health  and  well-being.  Information  regarding  this  menace  should 
be  accessible  not  alone  to  the  wage-earner  in  factory  and  shop, 
but  to  office  employees  and  those  who  are  domiciled  in  mansions 
on  the  boulevard. 

(b)  Beer,  Ale  and  Wine  Addiction:  Most  works  on  dietetics 
classify  beer,  ale  and  wine  among  the  food  accessories.  There  is 
practically  no  actual  food  value  in  any  of  these  drinks  and  nobody 
drinks  them  with  a  view  of  receiving  food  value  with  the  possible 
exception  of  the  man  who  has  been  taught  as  stated  above  that 


79 

"beer  is  liquid  bread."  It  is  even  doubtful  if  he  actually  believes 
it,  though  he  may  cite  that  in  his  argument  of  justification  for  its 
use.  It  is  the  influence  of  the  four  to  seven  or  ten  per  cent,  of 
alcohol  in  the  beer  that  leads  the  man  into  the  habit  of  makng 
it  a  regular  part  of  his  meals,  especially  his  mid-day  lunch  and 
perhaps  of  his  supper. 

Wine  is  used  as  a  food  accessory  almost  universally  in  southern 
Europe,  where  it  is  produced  in  great  abundance.  Until  recent 
times  its  use  found  some  justification  in  the  fact  that  many  of  the 
cities  of  southern  Europe  had  very  adequate  supply  of  very  ques- 
tionable water — water  contaminated  in  its  source,  in  its  trans- 
mission and  in  its  final  distribution.  The  people  feared  to  drink 
the  water,  properly  too,  and  they  recognized  in  wine  a  safer 
drink  than  water  presented  at  certain  times.  In  order  to  make 
sure  they  used  wine  all  the  time.  In  fact  they  had  no  way  of 
telling  when  their  water  was  fit  to  drink. 

But  this  fear  of  the  water  of  the  cities  of  southern  Europe  is 
no  longer  justified.  The  writer  has  used  this  water  freely  for 
drinking  purposes  in  many  of  the  cities  of  southern  Europe,  after 
first  ascertaining  that  all  the  laws  of  modern  hygiene  are  carefully 
observed  in  the  collecting,  transmission  and  distribution  of  the 
water  supply.  The  tables  are  now  turned  on  the  wine.  Water 
is  a  wholesome  natural  drink  and  we  know  wine  to  be  an  unwhole- 
some and  unnatural  drink.  There  is  a  gradual  awakening  of 
the  governments  of  Europe  to  this  fact.  It  is  probable  that  within 
the  next  generation  beer,  ale  and  wine  will  cease  to  be  classified 
as  food  accessories.  They  will  be  classified  as  harmful  drinks 
and  then*  use  will  be  very  much  restricted. 

(5)  Due  to  Desire  for  "Stimulation"  or  Narcosis. — Many  a 
wage-earner  begins  the  use  of  strong  drink  because  of  his  desire 
for  what  he  calls  a  "stimulant."  He  feels  tired,  he  may  even  be 
aching  with  fatigue.  He  believes  that  a  "stimulant"  will  help 
him  get  through  the  day.  A  dram  of  whiskey  or  brandy  eases 
his  pain  and  makes  him  unconscious  of  fatigue,  so  he  continues 
his  day's  work  convinced  that  his  dram  of  alcohol  helped  him 
with  his  work  affording  a  needed  stimulus.  In  the  light  of  modern 
researches  we  interpret  his  response  to  the  alcohol  very  differ- 


8o 

ently.  It  did  not  stimulate  him,  it  only  relieved  his  sense  of 
fatigue  and  pain  as  an  anesthetic  does.  Instead  of  being  a  stim- 
ulant it  was  really  a  narcotic.  Relieved  of  the  pain  and  the  sense 
of  fatigue  he  continued  his  work  to  the  end  of  the  day  only  to  feel 
a  recurrence  of  his  fatigue  all  the  more  extreme  as  the  reaction 
sets  in.  The  argument  which  he  used  to  justify  the  first  dram 
may  be  used  again  to  justify  a  second  dram,  so  he  drinks  again 
to  forget  his  weariness.  It  is  hardly  necessary  to  say  that  a  man 
who  starts  on  that  sort  of  a  campaign  soon  degenerates  into  the 
class  of  inefficient  workers.  Among  the  men  laid  off  from  the 
factory  he  is  in  the  first  lot  if  he  is  a  man  without  a  family.  If  he 
has  a  family  to  support,  the  manager  will  keep  him  until  he  be- 
comes an  actual  loss  to  the  company  in  inefficiency  and  cost. 
The  family  man  who  is  an  addict  of  alcoholic  beverages  will  prob- 
ably be  in  a  second  list  of  those  who  are  dropped  from  the  pay- 
roll. In  this  seeking  of  a  "stimulant"  lies  one  of  the  most  serious 
menaces  to  the  wage-earner  so  far  as  concerns  his  relation  to  drugs. 
Every  effort  should  be  made  to  disseminate  among  wage-earners 
a  knowledge  of  the  truth  regarding  alcohol.  Every  wage-earner 
in  the  world  should  be  taught  that  alcohol  in  any  form  as  bever- 
age, food  accessory,  or  medicine  is  a  narcotic  and  not  a  stimu- 
lant, that  it  is  a  dangerous  drug  because  its  moderate  use  is  likely 
to  lead  to  its  excessive  use  and  that  its  excessive  use  is  associated 
in  a  casual  relation  to  weakness,  disease,  degeneration  and  death. 

(6)  Due  to  Desire  for  Conviviality  and  Good  Fellowship. — Many 
a  man  who  feels  no  need  of  "stimulation"  does  feel  the  need  for 
companionship,  good  fellowship  and  conviviality.  Furthermore, 
he  has  a  right  to  these  things.  Man  is  a  social  animal  whose  high- 
est all-round  development  cannot  be  attained  in  solitude.  He 
needs  companionship  to  bring  out  his  best  qualities.  Consider- 
ing all  of  this,  it  is  easy  to  understand  how  the  man  who  has  just 
received  his  week-end  pay  envelope  goes  with  his  companions  and 
associates  into  a  neighboring  saloon  where  their  pay  checks  are 
cashed  and  he  sits  there  for  an  hour  or  so  relaxing  from  his  week's 
work,  telling  jokes  and  funny  stories  and  incidentally  setting  up 
the  drinks  for  the  half  dozen  men  who  sit  about  the  table  in  the 
alcove.  It  has  become  customary  in  America  for  each  of  the  other 


8i 

men  in  their  circle  to  set  up  the  drinks  for  the  crowd.  This  is  a 
most  unfortunate  thing,  because  if  there  are  six  men  in  the  group 
and  if  each  man  sets  up  the  drinks,  each  one  will  have  had  six  drinks 
before  their  little  social  gathering  is  broken  up,  but  six  drinks 
exceeds  all  bounds  of  moderation — it  is  excessive.  The  man 
goes  home  at  eight  or  nine  o'clock  instead  of  six  or  seven,  distinctly 
under  the  influence  of  intoxicants  and  with  an  appreciably  de- 
pleted purse.  It  is  hardly  necessary  to  further  depict  the  almost 
certain  downward  course  of  this  wage-earner.  Drug  addiction 
in  his  case  becomes  chronic  alcoholism.  He  gradually,  as  the 
years  go  by,  degenerates  first  into  an  inefficient  worker,  in  time  of  a 
dull  season  he  is  first  to  be  laid  off,  and  finally  becomes  a  continuous 
member  of  the  great  army  of  the  unemployed.  His  wife  and  chil- 
dren are  now  the  bread  winners  for  the  family  while  the  drink 
addict,  who  at  forty-five  or  fifty,  should  be  at  the  climax  of  his 
industrial  efficiency,  because  he  should  now  work  only  not  with 
trained  hands  but  also  with  ripe  experience  and  judgment — 
mopes  and  smokes  and  growls  at  home,  his  own  health  wrecked 
and  the  health,  happiness,  education  and  general  well-being  of 
his  children  seriously  menaced  if  not  actually  impaired. 


XI 
HOME  SURROUNDINGS. 

By  THOMAS  D.  DAVIS,  M.D.,  Ph.D.,  Pittsburgh. 

An  ideal  home  is  one  where  the  physical,  mental  and  moral 
welfare  of  the  family  is  developed  in  the  best,  or  highest,  man- 
ner possible.  Such  a  home  in  the  apartment  houses  of  a  modern 
city  is  an  impossibility.  For  while  extreme  care  might  develop 
the  mental,  and  to  some  extent  the  moral  natures,  in  such  apart- 
ments, yet  the  physical  strength  would  have  to  depend  almost 
entirely  upon  outside  influences.  Even  if  properly  prepared  food 
is  supplied,  fresh  air,  sunlight  and  proper  heating  are  to  a  great 
extent  wanting.  If  this  statement  is  true  of  the  most  palatial 
apartments,  how  much  more  serious  is  the  condition  in  those 
apartments  designed  to  house  the  most  people  in  the  smallest 
space  possible?  This  deficiency  is  not  only  true  concerning 
physical  needs,  but  the  more  contracted  the  space  the  less  chance 
there  is  for  mental  and  moral  uplift.  Take  music,  which  every- 
where is  recognized  as. elevating;  its  practice  is  forbidden  in  many 
apartments,  while  the  lack  of  privacy  is  far  from  conducive  to 
good  morals.  It  is  not  the  children  alone  who  are  thus  deprived 
of  the  benefits  of  ideal  housing,  but  the  parents  also. 

Child  nature  demands  relaxation  and  exercise,  but  where  and 
how  are  city  children  to  get  it?  Few  city  homes  have  yards, 
or  is  there  vacant  ground  where  they  can  play,  while  usually  it  is 
a  long  distance  to  the  parks,  even  if  they  have  no  keep-off -the- 
grass  signs  in  them.  The  streets  are  dangerous  for  play  and  the 
time-honored  hop-scotch  is  forbidden  on  the  sidewalks.  No 
longer  may  children  play  I-Spy  or  Hunt  the  Hare  in  the  streets 
nor  ride  bicycles  or  use  roller  skates  on  the  sidewalks ;  the  police- 
men watch  that  the  rights  of  our  citizens  are  maintained.  More 
than  one  boy  fourteen  years  old,  out  on  our  Juvenile  Court  Farm, 
has  said  to  me:  "Until  I  came  here  I  never  threw  a  stone  as  far 
as  I  wanted  to,  nor  hollered  as  loud  as  I  could!"  To  meet  this 
absolute  need  of  play  some  cities  in  their  great  generosity  have 
provided  small  grounds.  They  have  usually  located  these  where 


83 

property  could  be  bought  the  cheapest,  rather  than  considering 
where  they  would  be  the  most  convenient  for  the  children.  Not 
only  are  the  best  of  these  grounds  inadequate,  but  in  our  wisdom 
we  have  tried  to  teach  children  "organized  play:"  This  is  a 
series  of  trivial  games,  or  drills,  that  to  all  intents  is  a  system  of 
work,  devoid  of  most  of  the  elements  of  real  play!  At  stated 
periods  exhibitions  of  these  drills  are  given  and  the  delighted 
public  vociferously  applaud,  while  the  paid  conductors  exclaim: 
"See  how  beautifully  we  have  taught  your  children  to  play!" 
Last  year  our  city  paid  $5 7,000  to  teach  our  children  how  to  play. 
On  the  other  hand,  a  perfect  house  and  grounds  may  not  con- 
tain a  true  home.  We  are  so  given  to  charging  every  short- 
coming to  environment  that  we  are  prone  to  overlook  the  per- 
sonal equation.  Where  among  the  poorer  classes  bad  parental 
oversight  may  be  charged  to  ignorance,  too  often  in  the  home 
of  luxury  it  is  the  result  of  indifference,  or  neglect.  Children  of 
the  wealthy  are  frequently  brought  up  more  by  servants  than  by 
their  parents,  and  thus  moral,  mental  and  physical  bad  habits 
are  the  result.  Even  where  parents  have  the  interest  of  their 
children  at  heart,  they  sometimes  are  so  engrossed  in  business 
and  social  cares,  or  have  so  little  aptitude  for  such  delicate  and 
important  work  that  their  oversight  is  imperfect  if  not  disas- 
trous. The  incorrigible  and  degenerates  are  not  all  from  the 
homes  of  poverty.  Many  of  our  most  distinguished  and  honored 
citizens  have  come  from  very  humble  houses.  It  is  the  aspiring 
mind  and  loving  heart  within  a  building  that  elevates  it  into  a 
home.  Indeed  it  would  seem  as  if  discouraging  environments 
only  stimulated  ambition  in  some.  Andrew  Carnegie  was  brought 
up  in  a  very  humble  house,  but  there  was  a  faithful  Scotch  mother 
in  it  that  made  it  a  true  home.  Lincoln's  early  house  had  but 
three  sides,  but  a  devoted  stepmother  made  it  a  home.  Gar- 
field's  dwelling  was  of  the  humblest  sort,  but  his  Christian  mother 
made  it  an  exalted  home.  Has  not  too  much  effort  been  expended 
on  mere  inert  materials  that  make  houses,  rather  than  on  plia- 
ble minds  and  hearts  that  make  a  home?  The  great  Park  Hotel 
in  New  York  was  once  A.  T.  Stewart's  unsuccessful  home  for 
working  woman!  Mere  improvement  of  houses  without  extra 


84 

efforts  to  improve  their  inmates,  in  the  long  run,  have  been  fail- 
ures. Much  thought  and  money  have  been  expended  on  hy- 
gienic housing  propositions.  It  has  always  been  an  attractive 
field  for  philanthropists,  but  it  has  invariably  been  found  that  it 
is  easier  to  supply  suitable  houses  than  it  is  to  find  suitable  in- 
habitants for  them. 

I  have  recently  been  through  a  large  section  of  the  bituminous 
coal  fields.  At  the  great  majority  of  the  works  there  are  no  more 
comfortable,  or  sanitary  houses  for  laborers  in  the  world.  These 
houses  are  separated  from  each  other  and  have  an  abundance 
of  light  and  air.  Most  of  them  have  front  yards  and  garden 
room  in  the  rear.  They  are  usually  of  two  stories  and  have 
modern  sanitary  appliances,  as  far  as  possible,  yet  many,  very 
many,  of  these  look  more  as  if  they  were  cattle  pens  than  homes 
for  human  beings.  As  a  rule  their  front  yards  are  entirely  neg- 
lected and  not  a  vegetable  is  raised  in  their  gardens.  This  is  all 
the  more  marked  because  immediately  adjoining  may  be  houses 
with  flowers  and  shrubbery  in  their  front  yards  and  profitable 
gardens  with  their  attractive  foliage  and  growth.  Mostly,  how- 
ever, unkempt  women  and  loafing  men  are  lolling  around  in  front 
with  pigs,  chickens  and  children.  The  beer  wagon  stops  oftener 
at  these  latter  houses  than  does  the  milk  cart.  The  Sundays 
and  holidays  of  the  men  are  mostly  spent  with  beer  kegs  in  the 
woods  or  along  the  rivers,  sometimes  accompanied  by  their 
women  and  children.  Their  houses  are  not  homes  and  present 
no  attractions  for  them,  yet  these  men  receive  the  highest  pay 
in  the  world,  for  the  same  kind  of  work.  One  of  our  largest  em- 
ployers of  labor  told  me  recently,  that  when  their  men  went  wrong 
they  invariably  traced  it  to  miserable  housekeeping  and  slovenly 
women.  The  floors  of  some  of  these  houses  are  not  scrubbed 
for  months  and  they  swarm  with  vermin.  Nor  is  it  ignorance 
alone  of  good  housekeeping  that  leads  to  such  foul  conditions. 
I  know  several  women  who  were  neat  and  tidy  domestics  in  fine 
homes,  who  are  now  married  to  good  tradesmen,  but  their  dwell- 
ings are  now  indescribably  dirty  and  disorderly  and  their  children 
the  very  worst  in  their  neighborhood.  I  have  known  neat,  clean 
and  convenient  houses,  just  new,  that  in  a  few  months  were  too 


85 

filthy  and  unhygienic  to  be  described.  The  cause  of  this  retro- 
grading is  mostly  beer,  or  the  depressing  influence  and  discour- 
agement of  strikes. 

Much  of  the  crowding  in  the  more  respectable  tenements  is 
entirely  unnecessary,  and  is  more  the  result  of  cupidity  than 
poverty.  In  the  poorer  districts  I  have  known  laborers  getting 
$2.25  a  day,  who  slept  in  cellars,  five  to  ten  in  one  room,  costing 
them  fifty  cents  a  week,  and  they  were  simply  saving  up  to  get 
back  and  loaf  in  dear,  dirty  old  Italy.  The  Huns  in  our  coke 
regions  are  notoriously  degraded.  The  condition  of  some  of  their 
sick  and  injured  when  they  are  brought  to  our  city  hospitals  is 
simply  horrible  beyond  belief,  yet  their  company  houses  are 
almost  invariably  well  built,  comfortable  and  convenient.  A 
pen  of  hogs,  no  matter  how  fine  the  building  may  be,  is  still  a 
hog  pen. 

With  such  parents,  who  create  such  surroundings,  how  is  it 
possible  for  their  children  to  advance?  Take  these  same  children 
out  in  our  Juvenile  Court  farm,  where  in  simple  cottages  they 
have  been  trained  by  faithful  house  fathers  and  mothers,  and  their 
rapid  improvement,  in  every  way,  is  simply  wonderful,  but  these 
same  simple  cottages  without  the  skilled  and  devoted  foster 
parents  and  teachers  would  accomplish  but  little  of  a  permanent 
value.  Unless  such  children  can  be  separated  from  their  parents 
there  is  but  little  hope  for  them.  Simply  improving  dwellings 
is  trying  to  purify  the  foul  stream  when  the  trouble  is  at  the  source. 
Purify  the  people  and  the  dwellings  will  become  pure. 

I  recognize  fully  the  crowded  condition  and  the  miserable 
accommodations  in  the  tenement  houses  of  our  cities,  but  even 
in  them  cleanliness  is  not  altogether  impossible  if  the  people  are 
clean.  The  very  worst  tenements  are  made  worse  because  the 
tenants  are  slovenly  and  lazy.  There  can  be  no  doubt  that 
more  disease  is  caused  by  the  way  a  house  is  kept  than  by  the 
house  itself,  no  matter  how  poor  it  may  be.  Only  those  whose 
duties  call  them  into  our  worst  tenements  can  realize  how  un- 
sanitary, not  to  say  filthy,  they  are  kept.  There  is  often  poverty 
in  everything  but  dirt.  Even  in  a  grade  better  apartments  there 
is  a  woeful  lack  of  cleanliness.  It  is  the  habit  of  many  in  these 


86 

to  clean  up  once  a  week  and  the  rest  of  the  time  the  house  is  in 
disorder,  confusion  and  dirt.  The  waste  in  most  of  these  houses, 
either  through  ignorance  or  indifference,  is  appalling,  while  poorly 
cooked  food  is  the  constant  source  of  physical  evil.  Our  schools 
have,  with  the  expenditure  of  much  money  and  time,  attempted 
to  overcome  this,  by  teaching  culinary  art  to  children  from  such 
homes.  It  has  not  been  a  real  success.  Domestic  science  kitchens 
have  been  fitted  out  with  appliances  never  dreamed  of  in  tene- 
ments. This  equipment  consists  of  glass  topped  tables,  marble 
sinks,  tile  tops,  refrigerators,  fine  cooking  utensils,  gas  stoves  with 
broilers,  toasters,  etc.  While  the  dishes  they  are  taught  to  prepare 
are  to  a  great  extent  an  impossibility  in  tenements,  the  same 
holds  true  of  similar  work  in  most  social  centers.  It  would  seem 
as  if  public  kitchens  should  prove  successful,  where  food  would 
be  prepared  more  economically  and  certainly  far  better  than  it 
can  possibly  be  done  in  most  tenements. 

Let  us  have  as  good  houses  as  we  possibly  can.  Let  us  supply 
every  convenience  and  sanitary  device  possible.  Let  nothing  be 
undone  to  give  everyone  the  best  environments  possible,  yet 
after  all  we  will  find  that  it  is  the  people  that  we  must  improve 
rather  than  their  houses  alone. 


XII 
IMPROPER  RECREATIONS. 

By  SHERMAN  C.    KINOSI.BY,  Chicago,  Director   Elizabeth    McCormick    Memorial  Fund; 
Former  Superintendent  United  Charities  of  Chicago. 

Man's  earlier  occupations  were  out  of  doors.  He  ranged  the 
forests,  tilled  the  fields  and  sailed  the  seas.  He  indulged  in  the 
chase,  and  both  his  labors  and  his  recreations,  which  were  often 
akin,  were  largely  in  the  open. 

With  the  coming  of  factory  conditions  and  city  life,  a  great 
change  has  taken  place.  The  ranch  and  the  farm  gave  way  to 
the  cottage  and  the  yard,  and  these,  in  turn,  yielded  to  the  flat 
and  the  tenement  which  covered  the  whole  block.  The  retreat 
from  the  open  is  well  nigh  complete.  The  tenement  surrounds 
the  factory.  A  short  walk  in  the  early  morning  hours  and  late 
at  night  takes  the  worker  to  and  from  his  dwelling  and  the  factory 
where  he  labors  at  a  desk,  a  machine,  at  more  and  more  spe- 
cialized kinds  of  work.  He  carries  his  lunch  with  him,  and  this 
is  often  eaten  inside  the  building.  This  operation,  repeated  day 
in  and  day  out,  describes  the  orbit  of  his  life.  The  dwelling  is 
on  one  floor  and  consists  of  from  one  to  four  or  five  rooms,  aver- 
aging about  four  for  the  usual  worker.  Land  becomes  valuable 
in  these  congested  places  and  it  fills  up.  No  account  is  taken  of 
out-of-door  opportunities;  the  worker  will  not  stay  in  his  three 
or  four  rooms,  and  seeks  some  kind  of  recreation  from  his  circum- 
scribed and  monotonous  life. 

Since  the  worker  either  has  not  been  able  himself  to  look  out 
for  his  opportunities  for  recreation,  or  has  not  had  the  foresight 
to  do  it,  and  since  society  has  not  done  it,  this  field  of  activity, 
like  the  recreation  of  children,  has  been  appropriated  and  com- 
mercialized by  a  group  of  people  who  are  wise  in  their  generation. 
They  know  that  not  only  will  children  not  remain  in  these  two 
or  three  or  four  rooms,  but  that  neither  will  the  father.  Conse- 
quently, the  saloon,  the  dance  hall,  the  pool  room,  the  gambling 
house,  the  cheap  theater  and  other  sorts  of  commercialized 
amusement  have  sprung  into  existence  and  cater  to  the  "street 


88 

and  alley  time"  of  boys  and  girls  and  the  off  work  hours  of  the 
men. 

In  the  city  of  Chicago  there  are  7,000  saloons.  Often  every 
building  on  the  whole  side  of  a  block  is  a  saloon.  7,000  saloons 
in  the  city  means  one  saloon  for  every  70  adults.  About  the 
same  proportion  prevails  in  other  large  municipalities.  So,  the 
worker  having  spent  his  8-,  10-,  1 2-hour  day  in  the  factory,  with 
brief  intervals  at  home  for  his  morning  and  evening  meal,  finds 
himself,  with  companions,  in  some  one  or  other  of  these  indoor 
places  of  recreation.  The  saloon  still  counts  the  largest  num- 
bers. 

After  an  evening  thus  passively  spent,  often  with  the  accom- 
paniment of  intoxicating  drinks,  with  low-tone  scenes,  stories 
and  other  amusements,  usually  in  close  and  vitiated  atmosphere, 
the  worker  returns  to  his  home  to  spend  his  sleeping  hours  also 
in  congested  quarters. 

The  Juvenile  Protective  Association  of  Chicago,  in  a  study  of 
the  recreations  of  young  people  about  a  year  ago,  found  that  on 
an  average  of  about  80,000  young  people  a  night  were  to  be 
found  in  the  dance  halls,  largely  connected  with  saloons,  in  the 
city  of  Chicago. 

Some  measure  of  the  moral  perils  connected  with  this  kind  of 
recreation  is  indicated  in  the  number  of  arrests,  of  the  convic- 
tions in  courts,  and  of  the  recruiting  that  goes  on  in  the  red  light 
districts.  There  is  probably  no  data  on  which  to  base  any  esti- 
mate of  the  lack  of  efficiency  and  physical  deterioration  occa- 
sioned by  these  false  standards  of  recreation. 

One  of  the  things  strikingly  impressed  upon  social  workers  when 
they  come  into  intimate  and  confidential  relations  with  our  immi- 
grant population  is  the  distress  they  experience  in  trying  to  bring 
up  their  children  under  the  new  conditions. 

The  majority  of  them  are  accustomed  to  greater  out-of-door 
activities  in  the  lands  from  which  they  come.  The  folk  songs, 
games  and  dances,  the  times  enjoyed  by  the  family  together, 
are  among  the  charms  of  life  not  only  in  Italy,  but  in  France, 
Germany,  Sweden,  and  other  countries  as  well.  There,  it  is 
more  the  custom  for  the  whole  family  to  have  their  good  times 


89 

together.  Here,  the  special  places  for  the  men  in  the  way  of 
saloons  and  other  forms  of  so-called  recreation,  and  those  that 
appeal  particularly  to  the  children,  help  to  break  the  family  up 
and  progressively  to  instal  disintegrating,  specialized  forms  of 
diversion. 

This  makes  the  matter  of  present  form  of  amusement  of  double 
consequence.  It  has  its  immediate  effect  on  those  who  are  par- 
ticipating in  the  different  kinds  of  recreation,  and  it  is  also  mak- 
ing habit  and  tradition  which  will  descend  to  the  children.  It  is 
bad  enough  to  register  the  consequences  of  recreation  on  wrong 
lines  in  the  bodies  of  those  who  participate  in  and  make  a  habit 
of  that  kind  of  recreation.  It  decreases  efficiency,  lowers  the 
tone,  and  is  a  losing  game  for  those  who  practise  it.  It  is  at  the 
same  time  insidiously  confirming  in  the  minds  and  practices  of 
people  acquiescence  in  and  a  demand  for  that  particular  form  of 
city  life.  It  is  a  distinct  loss  to  any  community  to  have  it  in- 
stilled in  the  minds  of  its  growing  children  that  it  is  an  intrinsic 
part  of  a  city  to  have  saloons  and  brothels,  arrests,  disorderly 
houses,  and  a  whole  line  of  low-tone,  destructive,  so-called  recrea- 
tion agencies. 

One  of  the  most  hopeful  developments  that  has  taken  place 
in  our  modern  life  is  the  bringing  back  to  the  people  of  open  spaces, 
of  swimming  pools,  field  houses,  playgrounds,  recreation  facili- 
ties of  a  wholesome  sort. 

As  city  life  is  organized  to-day,  the  working  man  is  unable  to 
provide  proper  recreation  for  himself  and  for  his  children.  It 
must  be  a  community  affair.  Together  the  people  must  plan 
and  make  provision  for  this  matter  of  recreation. 

I  once  heard  a  man  say  that  he  felt  it  almost  more  important 
to  know  what  the  young  men  in  his  employ  did  outside  their 
working  hours  than  what  they  did  while  employed. 

By  the  very  weight  of  present  adjustments,  the  temptation  is 
placed  on  the  average  working  man  to  make  a  wrong  use  of  his 
recreation  moments.  Some  of  the  most  cheering  sights  that  one 
sees  in  England  are  the  bowling  greens,  the  cricket  fields  and 
other  places  of  recreation  scattered  about  the  cities,  and  to  see 
the  working  people  after  hours  spending  the  long  twilight  in  some 


9o 

form  of  delightful  out-of-door  recreation.  Great  use,  also,  is 
made  of  vacant  spaces — allotments,  they  are  called — along  rail- 
road tracks.  Indeed,  all  the  land  about  the  cities  is  parceled 
out  to  those  who  wish  to  use  it  for  flower  and  vegetable  gardens; 
and  as  one  travels  about  one  sees  hundreds  of  people — men, 
women  and  children — employed  in  this  way  during  their  leisure 
moments. 

In  the  parks  about  Paris  one  will  see  whole  families,  father, 
mother,  children,  the  grandfather  and  the  grandmother,  all 
playing  together,  or  with  employments  and  recreations  suitable 
to  each  group. 

In  Germany,  the  average  working  man  loves  to  spend  his  Sun- 
day in  the  open  air.  In  the  large  cities  they  start  early  in  the 
morning  with  their  whole  family,  even  the  babies.  They  take 
their  dinner,  the  children  their  playthings,  the  mother  some 
needlework.  By  train  or  trolley  they  reach  some  place  in  the 
country  and  settle  under  a  tree  in  the  meadow,  on  the  bank  of 
a  river,  at  any  place  they  like,  for  the  day.  In  the  smaller  places 
where  the  open  country  can  be  reached  more  easily,  they  some- 
times prefer  having  an  early  dinner  at  home,  but  the  afternoon 
is  spent  out  in  the  open. 

Around  nearly  all  the  large  German  cities  are  so-called  garden 
colonies.  A  big  area  is  divided  into  small  lots  that  are  left  for 
garden  purposes.  The  single  lots  are  sometimes  only  about  16 
to  33  feet,  but  the  tract  contains  a  little  cottage  or  arbor,  a  small 
lawn  and  heap  of  sand  as  a  playground  for  the  youngsters ;  and  in 
these  places  an  abundance  of  flowers  and  vegetables  are  raised. 
Many  working  people  seize  this  opportunity  to  have  a  bit  of 
land  of  their  own.  These  garden  colonies  are  accessible,  and 
every  free  hour  on  Sundays  and  holidays  is  spent  there. 

This  observation  has  been  made  by  a  German  social  worker: 
"There  is  no  sport  that  might  be  called  the  National  German 
sport.  It  is  perhaps  due  to  this  fact  that  Germany  does  not  suffer 
so  much  as  other  nations  do  from  the  dissolution  of  the  family. 
Until  now,  the  recreation  opportunities  for  the  working  people 
helped  to  draw  the  family  together,  and  one  thing  that  has  re- 


91 

tarded  the  more  formal  organization  and  specialization  of  sport 
is  that  it  would  tend  to  separate  the  family."  Walking,  bicycling, 
hill  climbing,  swimming,  rowing,  all  are  very  popular  in  the  coun- 
tries abroad.  They  have  paid  greater  attention  to  the  care  of 
streams  and  of  water  resources  than  has  been  the  case  in  this 
country. 

In  England  the  Half  Holiday  Association  is  an  indication  of 
the  value  that  is  placed  on  recreational  facilities.  This  Associa- 
tion has  equipped  country  houses  and  places  that  make  a  nice 
destination  for  a  half  day's  walk  or  bicycle  ride.  Here,  some- 
body is  in  attendance  to  act  as  host,  and  the  fine  old  English 
places  receive  the  people  who  are  on  the  walk  or  the  ride  and 
provide  meals  or  accommodation  for  the  night. 

What  we  want  in  this  country  is  to  create  an  appetite  for  the 
open  air,  for  wholesome  recreations,  a  love  for  trees  and  grass 
and  flowers — for  God's  great  out-of-doors.  It  is  becoming  more 
difficult  to  get  such  things,  but  out-of-doors  is  a  big  place.  There 
is  an  abundance  of  fresh  air  and  of  sunshine.  These  things  can 
be  made  available  for  almost  every  man,  woman  and  child,  if 
only  the  community  appreciates  the  necessity  for  such  things. 
We  need  them  and  must  have  them. 

We  want  to  stop  this  tendency  of  instilling  in  the  minds  of  our 
growing  children  that  saloons,  dance  halls,  passive  recreations, 
are  the  right  kind  of  thing.  Vicarious  exercise  will  save  no  one. 
It  is  not  sufficient  to  sit  around  a  prize  ring  or  on  baseball  bleachers, 
on  benches  in  stuffy  moving  picture  shows,  and  watch  somebody 
else  in  action.  The  individual  must  move  his  own  muscles, 
must  bathe  his  own  lungs  in  fresh  air,  must  let  the  sunshine  do 
its  work  on  its  own  face  and  arms.  We  want  to  give  the  out-of- 
doors  back  to  the  people.  We  want  each  individual  to  have  the 
right  kind  of  facilities,  to  acquire  right  tastes  and  habits  in  recrea- 
tion, and  to  hand  down  to  his  children  the  right  kind  of  tradi- 
tions in  recreation.  It  is  a  great  thing  for  a  nation  to  have  the 
right  kind  of  songs.  Is  it  not  fully  as  important  that  our  recrea- 
tion and  play  should  be  upbuilding,  helpful,  satisfying  and  en- 
nobling? 


XIII 


DISCUSSION 

Dr.  L.  Duncan  Bulkley,  New  York  City: 

I  think  we  cannot  thank  Dr.  Hoffman  enuf  for  bringing  to  us  this  interesting 
paper  upon  the  local  cause  of  cancer.  Those  of  us  who  are  studying  the  disease 
will  recognize,  I  think,  that  it  is  suggestiv  in  regard  to  the  action  of  light. 
Cancer  is  an  aberrant  cell  in  the  human  body.  It  just  so  happens  that  I  am 
to  read  a  paper  on  cancer  in  the  Pathological  Section  of  the  American  Medical 
Association,  so  I  happen  to  be  pretty  full  of  this  subject.  We  find  that  the 
Cohnheim  theory  of  "embryonic  rests"  is  probably  true;  that  these  rests 
are  hi  every  one;  that  they  remain  unproductiv  for  a  great  number  of  years 
and  then  take  on  this  aberrant  action.  Cancer  is  only  the  ultimate  result 
of  something  that  has  gone  wrong  before.  It  is  not  a  disease  coming  from  the 
outside,  not  infectious,  not  contagious,  but  simply  the  starting  up  of  some  cells 
which  then  take  on  this  morbid  action.  What  is  the  fundamental  cause  of 
it?  The  meat-eating  of  England  has  increast  of  late  years  so  that  now  there 
are  some  130  Ibs.  of  meat  consumed  in  England  for  each  man,  woman  and 
child  per  year.  Among  the  higher  classes  from  180  to  230  Ibs.  of  meat  are 
consumed  in  addition  to  game,  fish,  eggs,  etc.  This  is  more  than  double 
the  amount  in  fifty  years.  During  that  period  of  fifty  years  cancer  has  in- 
creast four-fold,  and  one  cannot  help  believing  that  there  is  some  relation  be- 
tween the  two  facts.  In  New  York,  cancer  has  not  greatly  increast  in  the 
last  five  years.  I  explained  in  my  paper  that  this  was  probably  due  to  so 
many  of  our  immigrants  living  upon  their  former  food  of  a  vegetarian  charac- 
ter. In  Baltimore,  where  there  is  not  the  immigrant  class,  cancer  has  in- 
creast ii  per  hundred  thousand.  In  seven  of  our  large  cities  cancer  has 
increast  seven  per  cent  hi  the  last  five  years.  In  the  cities  presenting  this 
increase  there  has  been  the  increase  in  meat  eating  and  coffee  drinking. 
I  think  it  is  a  mistake  to  look  wholly  to  local  causes. 

Mr.  Lewis  T.  Bryant,  Trenton,  N.  J.: 

I  should  like  to  ask  Dr.  Hoffman  whether  any  precautionary  measures  are 
being  taken  in  England,  or  whether  they  have  devised  any  remedial  features 
to  offset  the  inception  of  cancer? 

Dr.  F.  L.  Hoffman,  Newark,  N.  J. : 

Persistent  efforts  have  been  made  to  improve  conditions  in  the  pitch  and 
tar,  or  artificial  fuel  briquetting  industries,  but  the  results  have  not  been 
entirely  satisfactory.  In  the  main,  reliance  is  placed  upon  absolute  cleanliness, 
and  it  is  held  that  the  immediate  removal  of  the  irritating  dust  would  be, 
as  a  rule,  effectiv.  The  subsidiary  and  more  elaborate  and  costly  legal  pro- 
tectiv  requirements  were,  on  the -whole,  found  to  be  the  least  useful.  The 
principal  difficulty  was  experienced  in  securing  the  cooperation  of  the  men 
who  objected  to  the  compulsory  bathing  and  washing  requirements. 


93 

Mr.  Bryant: 

What  particular  type  of  dust  would  be  calculated  to  induce  cancer? 

Dr.  Hoffman: 
The  dust  of  the  pitch. 

Mr.  Bryant: 

Was  not  the  cancerous  effect  rather  due  to  contact  of  the  dust  with  the  skin 
than  from  the  breathing  of  it? 

Dr.  Hoffman: 

The  cancerous  effects  were  due  chiefly  to  the  contact  of  the  dust  with  the 
skin  and  the  resulting  irritation.  The  settling  of  the  dust  in  the  sweating 
pores  of  the  body  was  held  to  be  the  direct  causativ  factor. 

Mr.  H.  W.  Jordan,  Syracuse: 

We  had  an  operation  which  ground  pitch  very  fine.  Some  of  the  men 
were  greatly  irritated  by  this  fine  dust,  particularly  in  warm  weather.  It 
had  a  penetrating  effect,  and  with  the  perspiration  seemed  to  go  right  into 
the  skin.  This  might  produce  more  cancer  than  ordinary  dust.  While 
some  men  were  quite  immune,  others  were  not  able  to  work  until  provision 
was  made  to  prevent  the  dust  in  the  room. 

Mr.  Bryant: 

In  regard  to  the  second  paper,  it  is  surprising  how  general  is  the  use  of  lead 
in  several  industries  in  most  of  the  States  of  this  country.  Perhaps  the 
United  States  has  been  more  derelict  in  the  matter  of  protection  than  any 
other  country  in  the  world.  Workers  where  lead  is  used  in  quantities  by  in- 
haling the  dust  have  their  vitality  so  impaired  that  they  are  likely  to  contract 
other  diseases  than  direct  lead  poisoning.  Dr.  Hamilton,  who  is  probably 
the  greatest  investigator,  aroused  the  several  State  Departments  to  do  some- 
thing along  the  line  of  remedial  work.  In  our  own  State  we  found  from  the 
records  of  one  physician  that  in  the  city  smelter  works  there  were  200  cases 
of  lead  poisoning  varying  from  the  usual  symptoms  of  lead  poisoning  down 
to  the  double  wrist  drop  and  total  paralysis. 

Dr.  C.  T.  Graham-Rogers,  New  York  City: 

One  fase  of  the  subject  of  lead  poisoning  is  laxity  of  laws  regarding  the 
house  painters.  We  find  that  many  cases  are  due  to  faulty  personal  hygiene. 
If  there  is  lack  of  facilities  for  proper  washing,  the  workman  will  not  take 
•care  of  himself.  In  the  erection  of  new  buildings  there  is  no  provision  made 
for  the  painter  to  wash  up,  and  the  best  he  can  do,  perhaps,  after  the  work 
is  finisht  is  to  use  a  piece  of  waste  or  paper  for  wiping  his  hands.  There  is 
no  hot  water  and  no  soap  for  his  use.  I  remember  one  instance  in  which 
rigid  requirements  of  the  law  were  complied  with  but  in  which  case  after  case 


94 

of  lead  poisoning  develop!.  Here  I  found  that  there  was  litharge  in  the  water 
tank.  Physicians  are  not  working  hard  enuf  to  prevent  lead  poisoning  in 
not  reporting  cases  and  not  learning  to  recognize  lead  poisoning.  When 
a  case  comes  to  a  physician  the  trouble  is  not  taken  to  inquire  into  the  nature 
of  the  work  of  the  patient.  A  large  number  of  cases  are  being  treated  as 
anemias.  I  appeal  to  the  physicians  to  further  the  reporting  of  lead  poisoning. 
It  is  only  upon  our  morbidity  statistics,  not  our  mortality  statistics,  that  we 
can  accomplish  results.  Let  us  help  the  people  now  while  they  are  alive  and 
not  wait  until  they  are  dead. 

Mr.  Bryant: 

Dr.  Rogers  spoke  of  the  value  of  reporting  cases  of  lead  poisoning.  I  do- 
not  think  the  general  practitioner  appreciates  what  a  help  that  would  be 
to  the  official  in  charge  of  the  State  Department.  If  we  could  back  up  our 
argument  by  showing  the  number  of  cases  of  lead  poisoning  occurring  under 
these  circumstances  we  have  the  best  means  of  securing  improved  conditions. 
I  should  like  to  ask  Dr.  Rogers  in  regard  to  machinery  hazard,  what  standard 
of  air  movement  they  require  for  furnaces? 

Dr.  Rogers: 

We  have  not  set  any  specific  standard.  We  take  each  case  on  its  merits. 
Our  mechanical  engineer  is  trying  to  look  up  standards,  but  finds  it  a  difficult 
matter.  We  have  in  a  way  tried  out  the  matter  upon  illuminating  gas,  but 
even  that  is  difficult  on  different  machines. 

Mr.  Bryant: 

Mr.  Roach  mentioned  the  old  type  of  hood.  This  was  placed  about  the 
face  of  the  man  so  that  the  exhaust  of  noxious  fumes  would  be  taken  right 
past  the  man's  face.  In  this  way  the  very  thing  that  the  effort  was  made  ta 
avoid  was  brought  about.  We  have  made  quite  a  number  of  experiments. 
One  is  to  have  a  duct  run  down  from  the  height  of  the  man,  and  having  a 
hole  in  the  back  of  the  hood  so  that  the  fumes  are  drawn  away  from  the  man, 
down  and  up,  and  thus  avoiding  his  contact  with  them. 

Dr.  Rogers: 

Upon  that  point  we  have  set  this  as  a  rule — that  the  dust,  fumes,  gas  or 
vapor  must  be  removed  away  from  the  worker,  and  directly  at  the  point  of 
origin.  There  must  be  a  standard  of  1,000  ft.  of  air  per  minute. 

Dr.  Helen  C.  Putnam,  Providence: 

Do  you  test  the  standard  of  1,000  ft.  of  air  per  minute  with  an  anemometer? 

Dr.  Rogers: 
We  do. 


95 

Mr.  Bryant: 

The  question  of  child  labor  has  been  pretty  thoroly  discust  in  all  parts  of 
the  country.  The  Child  Labor  Committee  has  done  splendid  work  and  has 
prepared  a  uniform  Child  Labor  Bill  which  is  adopted  with  considerable 
modifications  in  some  parts  of  the  country.  We  adopted  in  our  State  a  bill 
limiting  the  hours  of  labor  for  minors  under  14  years  to  not  more  than  eight 
hours  a  day  and  not  more  than  48  hours  a  week.  We  specify,  in  particular 
the  occupational  industries  which  would  be  harmful.  We  submitted  the  bill 
to  Mr.  Lovejoy  after  we  had  prepared  it.  He  was  much  pleased  with  it  and 
will  probably  make  further  use  of  it. 

Dr.  Edward  Jackson,  Denver: 

Mr.  Lovejoy  sent  with  his  paper  a  preamble  and  series  of  resolutions. 
(Dr.  Jackson  read  the  resolutions  and  they  were  referred  to  Council  under 
the  standing  rule.  They  were  subsequently  reported  back  from  Council 
and  as  adopted  by  the  Academy  are  as  follows:) 

WHEREAS,  many  thousands  of  children  under  sixteen  years  of  age  are 
employed  in  the  United  States  in  gainful  occupations  under  improper  condi- 
tions, resulting  in  the  impairment  of  their  health  and  future  well-being,  as 
demonstrated  in  the  recent  investigation  made  by  the  Federal  Government, 
which  shows  that  37  per  cent  of  the  deaths  among  cotton  mill  operatives  in 
three  New  England  cities  and  41  per  cent  in  three  southern  cities  were  due  to 
tuberculosis  in  the  three-year  period  1905-1907;  and 

WHEREAS,  nineteen  states  and  the  District  of  Columbia  have  already 
enacted  laws  limiting  the  hours  of  labor  for  children  under  sixteen  years  of 
age  to  eight  per  day  and  prohibiting  such  children  from  working  at  night  or 
at  dangerous  occupations;  now,  therefore,  be  it 

Resolved  by  the  American  Academy  of  Medicine  that  we  commend  those 
states  which  have  adopted  legislation  to  protect  children  under  sixteen  years 
of  age  from  the  disastrous  consequences  of  unsuitable  work  and  bad  industrial 
conditions,  and  urge  all  other  states  to  establish  for  the  benefit  of  such  children 
the  eight-hour  work  day  and  the  prohibition  of  labor  at  night,  or  in  any 
hazardous  employments,  and  to  this  end  we  recommend  that  the  medical 
profession  generally  advocate  the  passage  of  such  laws  by  the  legislatures  of 
their  respectiv  states. 

Mr.  Bryant: 

One  of  the  most  serious  features  of  the  industrial  problem  for  the  working 
of  women,  in  addition  to  the  long  hours,  is  the  matter  of  providing  seats  for 
women  when  possible.  This  is  sometimes  a  difficult  thing  to  accomplish  in 
certain  types  of  industries.  All  know  the  anatomy  of  woman  and  that  such 
long  continued  standing  is  very  injurious.  I  think  legislation  should  be  di- 
rected along  the  line  of  providing  seating  for  women.  In  our  own  State 
we  are  trying  to  secure  this  in  factories.  There  are  many  things  at  which 


96 

women  can  work  as  well  sitting  down  as  standing.  I  understand  that  women 
working  upon  lead  are  affected  in  their  child-bearing  qualities.  I  have 
heard  that  in  some  of  the  industries  in  our  State  in  which  lead  is  encountered, 
of  the  women  engaged  in  the  work  very  few  are  capable  of  bearing  normal 
children.  Another  thing  which  should  receive  the  attention  of  the  legisla- 
tures of  this  country  is  some  restriction  about  the  employment  of  women  for 
a  certain  time  before  child-bearing  and  concerning  their  return  to  work 
afterward. 

Dr.  Rogers: 

I  would  like  to  call  attention  to  the  fact  that  whereas  we  hear  a  great  deal 
of  the  effects  of  wood  alcohol,  the  use  of  this  alcohol  is  not  so  great  in  industries 
as  one  would  be  led  to  suppose,  nor  are  the  results  so  dangerous  as  we  are 
led  to  believe.  There  is,  however,  in  use  the  amylic  alcohol,  the  dangers  from 
which  are  more  grave  than  from  wood.  The  effect  is  just  the  same  as  from 
the  wood  alcohol  and  it  is  used  to  a  much  further  degree.  I  have  seen  girls 
working  in  the  industries  where  it  is  used  practically  intoxicated.  Attention 
of  physicians  should  be  brought  to  this  matter. 

Dr.  John  L.  Heffron,  Syracuse: 

The  superintendent  of  a  large  steel  plant  in  our  city  told  me  that  nearly 
all  of  the  accidents  that  occur  in  that  plant  take  place  as  the  result  of  fatigue 
in  the  latter  part  of  the  afternoon,  and  that  on  Monday,  after  the  "fatigue" 
of  Saturday  and  Sunday,  the  accidents  are  particularly  numerous. 

Mr.  Bryant: 

The  remarks  of  Dr.  Heffron  emphasize  the  matter  of  improper  recreation 
on  Saturdays  and  Sundays  and  has  some  bearing  upon  the  question  of  im- 
proper lighting.  In  most  industries  a  large  number  of  accidents  occurring 
toward  evening,  which  may  be  occasioned  somewhat  by  the  natural  fatigue 
and  loss  of  vitality  of  the  operativ  after  working  long  hours  often  in  badly 
ventilated  work  rooms,  are  in  part  due  to  improper  lighting.  Too  much 
attention  can  not  be  placed  upon  the  matter  of  properly  lighted  rooms  and  the 
direction  of  the  light  that  the  person  at  the  machine  may  readily  see  the  needle. 
Passing  thru  Newark  recently,  I  saw  in  a  factory  the  upper  portion  of  the  build- 
ing used  by  the  officials,  good  lighting,  well  shaded,  while  immediately  under- 
neath, men  and  women  were  working  upon  machines  with  unguarded  lights 
and  the  light  thrown  into  the  eyes  and  not  upon  the  work.  I  think  this 
would  not  only  have  an  injurious  effect  upon  the  eyesight  but  also  cause  head- 
ache and  detract  from  the  efficiency  of  the  workmen. 

In  regard  to  Mr.  Roach's  paper,  it  is  difficult  to  cover  hi  a  comprehensiv 
manner  the  question  of  stagnant  air.  In  the  room  which  has  no  movement  of 
air,  even  tho  there  be  sufficient  cubic  air  space,  the  air  if  perfectly  dead  is 
quite  as  injurious  as  that  in  a  room  where  there  is  less  air  and  there  is  some 
movement  of  it. 


97 

Mr.  Jordan: 

In  certain  industries  in  which  steam  and  acid  vapors  are  to  be  disposed  of, 
means  have  been  introduced  for  bringing  the  heated  air  in,  not  only  along 
the  walls,  but  down  the  posts,  discharging  it  at  4  feet  above  the  floor.  The 
heated  air  coming  down  increases  the  temperature,  carries  off  the  steam  and 
gives  fresh  air  at  the  level  of  the  workers '  heads.  In  this  manner  the  heated 
air  duplicates  the  conditions  of  summer  air.  This  is  a  better  method  for 
ventilation  than  by  suction. 

Dr.  Putnam: 

I  should  like  to  ask  Mr.  Jordan  whether  any  record  is  kept,  or  examination 
made  daily  with  regard  to  the  temperature  and  humidity  of  the  air. 

Mr.  Jordan: 

We  have  done  some  work  in  keeping  records  of  the  temperature  and  hu- 
midity of  the  air.  In  general,  our  buildings,  which  are  high  and  open,  insure 
constant  motion  in  the  air.  The  humidity  ranges  from  60  per  cent,  to  70 
per  cent. 

Dr.  Rogers: 

The  State  Department  of  Labor  of  New  York  has  done  some  work  on  venti- 
lation. From  1907  to  the  present  date,  each  year  has  been  publisht  the  Re- 
port of  the  Commissioner  and  in  this  will  be  found  the  results  of  air  tests 
made  in  different  types  of  factories;  also  descriptions  of  apparatus  devised 
for  making  various  tests.  Those  interested  will  find  the  data  of  such  work 
in  these  reports. 


\ 


XIV. 

MEDICAL    INSPECTION    OF    THE    INDUSTRIES— NA- 
TIONAL,   STATE,    MUNICIPAL    OR    PRIVATE. 

By  RAY  I/STMAN   WILBUR.   A.M.,  M.D.,    Dean,  Stanford   University   Medical  School,   San 

Francisco. 

Medical  inspection  is  a  purely  human  phenomenon;  it  has  no 
nature-made  laws  controlling  it,  so  that  it  offers  an  opportunity 
for  the  intellect  of  man  to  choose  certain  methods  which  will 
be  feasible  under  existing  social  rules,  constitutional,  legislative 
and  judicial,  to  bring  about  certain  definite  results.  To  be  effec- 
tive, it  requires  inspectors  who  are  experts,  who  know  what  is 
to  be  accomplished  and  who  are  impartial  and  fair  and  prac- 
tical. If  we  were  planning  for  a  new  commonwealth  interested 
in  seeing  that  human  industry  did  not  exact  more  than  the  min- 
imum of  maimed  and  dead  bodies,  our  task  would  be  difficult, 
but  to  devise  a  method  that  will  not  conflict  with  the  thousands 
of  factors  concerned,  industrial  and  governmental,  is  at  present 
impossible.  The  division  of  the  United  States  into  nearly  half 
a  hundred  large  units  each  one  making  its  own  laws  concerning 
many  subjects  that  could  best  be  handled  by  the  national  govern- 
ment complicates  the  problem  greatly.  The  state  is  no  more 
of  a  proper  unit  for  most  industrial  legislation,  especially  where 
products  destined  for  interstate  commerce  are  concerned,  than 
it  is  for  the  making  of  the  laws  of  divorce  and  of  medical  practice. 
A  national  bureau  of  health  could  render  service  in  spite  of  the 
hampering  influence  of  state  laws  were  it  created.  But  it  could 
not  be  what  it  should  be,  creative  and  responsible.  At  the  best 
then,  we  can  only  discuss  those  things  that  are  possible  at  the 
present  time.  Evidently  the  practical  ideal  is  to  have  private 
medical  care  and  inspection  of  each  industrial  plant  controlled 
by  local  or  municipal  inspectors  with  the  authority  to  put  their 
recommendations  into  effect,  state  inspectors  to  study  the  prob- 
lems widely  and  to  make  suggestions  that  can  have  legislative 
backing  enough  to  be  effective  and  over  all  a  national  bureau 
giving  advice,  studying  methods,  training  workers,  and  with  a 


99 

limited  authority  to  see  that  the  broader  federal  laws  are  en- 
forced. The  whole  scheme  is  full  of  weakness  and  pitfalls  and 
only  a  wide-awake  interest  in  the  subject  can  make  it  even  passa- 
bly good.  Fortunately,  the  combined  conscience  of  society  is 
stirring,  the  dollar  is  tottering  on  its  glittering  pedestal,  and  many 
things  are  now  being  measured  in  other  terms  than  financial 
profit  and  loss.  The  compensation  acts  show  that  industry  must 
bear  the  burden  of  its  Moloch-like  existence.  It  is  beginning 
to  pay  to  protect  the  worker  from  harm;  the  by-products  of  leg 

/and  arms  and  tombstones  is  becoming  less  necessary  and  less 
productive.  The  best  way  to  save  money  is  not  to  spend  it; 
the  best  way  to  pay  the  working  man  and  make  him  pay  is  to 
keep  him  clean,  free  from  disease  and  foul  surroundings  and  happy. 
Society  is  tired  of  having  its  progress  stopped  by  the  unnecessary 
cripples,  the  blind,  the  paralyzed,  the  widow  and  the  orphan. 
Rat  traps  ought  not  to  be  made  at  the  cost  of  human  life,  the 
washing  of  towels  should  not  cost  us  human  arms,  and  we  should 
make  dishes  and  manufacture  paint  without  paralysis  or  fatal 
kidney  disease  as  the  price.  Some  factories  have  found  these 
things  out  and  they  are  making  private  inspection  pay.  The 
private  inspector  can  be  the  family  physician  of  the  industry, 
he  can  watch  over  the  health  of  its  workers  and  when  properly 
supported  can  organize  an  emergency  hospital  service,  make 
regular  examinations  and  forestall  disease  and  injury.  With  full 
knowledge  of  local  conditions  and  sympathy  with  the  work  a 
trained  man  can  do  great  good.  War,  as  well  as  industry,  has 
taught  us  that  the  first  care  given  the  injured  is  the  most  impor- 
tant. The  factory  needs  the  private  inspector  and  he  needs  the 
influence  and  the  supervision  of  the  trained  impartial  governmental 
inspector  over  hin.  In  Germany  and  England  the  private  inspec- 
tor of  the  lead  factories  must  be  a  man  acceptable  to  the  Govern- 
ment. 

The  private  inspector  of  a  large  factory  or  of  a  group  of  fac- 
tories, who  is  always  on  the  ground,  is  in  the  best  position  to  make 
use  of  the  practical  devices  for  the  protection  of  the  laborer  that 
are  the  most  apt  to  be  originated  by  the  man  of  mechanical  mind 
actually  at  work  in  the  industry.  He  can  stimulate  interest  in 


100 

the  care  of  the  workmen  on  the  part  of  the  owner,  can  show  the 
value  of  eye  and  other  examinations,  and,  if  need  be,  can  protect 
the  factory  against  small-pox  and  typhoid  by  vaccination  and 
against  many  other  diseases  by  early  segregation  and  proper 
sanitation.  There  is  no  reason  why  the  health  of  the  employees 
of  a  large  industrial  plant  should  not  be  protected  just  as  is  that 
of  our  army  at  present.  The  bitter  lessons  of  the  past  should  be 
learned  and  applied.  Flies,  rats,  mosquitoes,  toilets,  expec- 
toration, offer  problems  everywhere.  The  private  inspector  can 
solve  them  if  given  power  and  financial  assistance.  He  can  study 
the  occupational  diseases  of  his  own  particular  plant  and  contrib- 
ute much  to  their  eradication,  by  bringing  the  responsibility 
home  to  the  owner.  Certainly  we  must  find  room  in  our  scheme 
for  the  private  inspector,  "the  family  physician  of  the  plant." 
Without  him,  or  such  supervision  as  he  alone  can  give,  no  plan 
for  the  protection  of  the  employee  will  be  first-class. 

Next  to  the  private  inspector  will  come  the  local  municipal 
inspector  who,  except  for  the  control  of  contagious  diseases  and 
for  the  enforcement  of  ordinary  sanitary  regulations,  is  not  apt  to 
be  effective.  He  is  like  the  policeman,  too  close  to  his  job,  too 
apt  to  be  a  political  hack  and  too  readily  persuaded  and  moulded. 
In  order  to  get  the  most  out  of  the  police  power  in  its  relations 
to  industry,  the  officer  with  final  authority  should  at  least  have 
the  backing  of  the  state,  that  of  the  nation  would  be  better.  I 
have  often  thought  of  the  experience  of  a  friend  of  mine  in  San 
Francisco,  after  the  fire.  A  number  of  policemen  were  trying  to 
hold  back  a  large  crowd  from  crossing  Market  Street  at  a  certain 
point.  Along  came  a  squad  of  soldiers — one  private  was  assigned 
to  the  work  ineffectively  done  by  the  policemen.  Here  was  a 
stranger  under  orders — a  new  force — the  crowd  knew  the  police- 
man and  his  limitations  in  such  an  emergency.  The  private 
paced  back  and  forth,  no  one  stirred.  Finally  one  man  started 
to  run  across  the  street,  the  private  took  his  gun  by  the  butt, 
knocked  the  man  back  into  line,  and  marched  along  as  before. 
No  one  tried  it  again.  Here  was  an  impartial  citizen  with  a 
loaded  gun  carrying  out  orders — pulls,  graft,  blandishments 
did  not  apply. 


IOI 

So  should  it  be  with  the  medical  inspector,  impartiality,  power, 
effectiveness. 

The  state  can  do  better  than  the  municipality  or  county,  and 
to  it,  under  existing  conditions,  we  in  the  United  States  must 
look.  In  Massachusetts  a  good  scheme  has  been  worked  out. 
The  state  is  divided  into  health  districts  with  state  medical  in- 
spectors in  each.  They  have  full  power  to  investigate  contagious 
diseases,  but  their  eradication  depends  on  the  local  officer,  as 
does  also  the  mitigation  of  nuisances.  The  inspectors  act  as  inter- 
mediaries between  the  local  and  state  board  of  health  in  consider- 
ing all  influences  dangerous  to  public  health  and  in  the  preven- 
tion of  tuberculosis  and  of  other  diseases  dangerous  to  public 
health,  but  they  act  independently  of  local  authorities  in  the  in- 
vestigation of  the  health  of  minors  employed  in  factories  and  the 
sanitation  of  factories,  slaughter  houses,  public  buildings  and  tene- 
ments in  which  clothing  is  manufactured.  That  there  are  "twi- 
light zones"  where  there  is  overlapping  of  authority  and  where 
gaps  exist  is  evident,  and  in  these  lies  the  opportunity  for  poor 
work,  bad  conditions,  contests,  court  decisions  and  other  blocks 
to  effective  control.  The  actual  power  of  seeing  that  needed 
changes  are  made  and  regulations  enforced  should  be  in  the  hands 
of  the  state.  Legislatures  should  seek  for  more  centralization 
of  police  power  in  all  health  laws.  A  state  inspector  should  be 
able,  with  the  assistance  of  the  state  board  of  health,  to  close 
up  any  establishment  maintaining  dangerous  or  unsanitary 
conditions.  The  Massachusetts  law  sails  between  the  rocks  set 
up  by  multiple  units  of  government  and  is  worthy  of  imitation. 
Perhaps  it  is  the  best  we  can  do  at  present.  The  need  of  making 
the  municipality  responsible  in  many  health  problems  must 
of  necessity  limit  the  power  of  the  state.  The  knowledge  of 
local  conditions  and  the  need  of  prompt  action  makes  the  local 
forces  absolutely  essential  in  many  ways.  The  state  though  must 
feel  its  responsibility.  Legislative  appropriation  for  specific 
purposes  stimulates  a  sense  of  responsibility  and  is  to  be  systemat- 
ically encouraged  along  all  the  lines  of  public  health. 

We  can  hope  for  no  such  development  from  the  national  gov- 
ernment in  industrial  control  as  has  taken  place  in  the  history 


102 

of  the  U.  S.  Public  Health  and  Marine  Hospital  Service.  The 
establishment  of  sick  insurance  and  the  care  of  sailors  is  not  a 
matter  of  state  concern  and  the  great  power  of  port  quarantine 
cannot  apply  to  the  industries.  The  national  government  can, 
though,  make  investigations  such  as  those  of  the  present  U.  S. 
Bureau  of  Labor,  without  formulating  laws  or  regulations.  Pub- 
licity is  the  greatest  desideratum  and  sound  knowledge  and  the 
training  of  sound  investigators  can  be  taken  hold  of  by  such 
forces  as  the  public  health  service,  the  bureau  of  labor,  and  par- 
ticularly by  a  department  of  health  when  one  is  created.  As 
previously  indicated  my  faith  in  national  regulations  of  large  en- 
terprises is  greater  than  in  that  of  the  state,  but  I  see  no  way  to 
bring  it  about  in  this  connection.  One  who  has  seen  the  long  arm 
of  the  national  government  impartially  administer  justice  where 
state  and  local  governments  have  been  grotesquely  laughed 
at,  yearns  for  such  control  over  conditions  where  money  and  life 
combat  together  on  a  large  scale. 

It  is  clear  that  the  way  has  been  found  for  a  fairly  satisfactory 
regulation  of  the  industries  in  their  relationships  to  the  health 
of  the  workers.  The  public  has  recognized  the  need  and  in  many 
ways  the  industries  are  meeting  the  details.  We  can  urge  then 
the  desirability  of  the  private  inspector,  the  need  of  the  state  in- 
spector, with  power  enough  to  be  effective  and  without  power 
enough  to  displace  the  responsibility  of  the  local  inspector, 
the  abolition  of  as  many  of  the  "twilight  zones"  of  responsibility 
as  possible  and  over  all  an  investigating,  training,  stimulating 
force  under  the  national  government. 


XV. 
MEDICAL  SUPERVISION  IN  DANGEROUS  TRADES> 

By  GEORGE  M.  PRICE,  M.D.,  Director,  Joint  Board  of  Sanitary  Control  in  the  cloak,  suit 
and  skirt,  and  dress  and  waist  industries.  New  York  City. 

Industrial  efficiency  is  not  an  engineering  problem  alone.  It 
is  also  a  medical  problem.  The  human  factor  in  industry  is  more 
important  than  the  mechanical  and  technical  devices  and  ap- 
pliances and  needs  medical  supervision  surely  no  less  than  the  me- 
chanical parts  need  engineering  supervision. 

Medical  supervision  is  necessary  in  all  trades  and  all  industrial 
establishments.  But  it  is  especially  imperative  in  what  are  called 
"Dangerous  Trades."  By  these  are  meant  all  trades  where  there 
are  poisons,  gases,  fumes,  or  infections  to  be  found,  either  due  to 
materials  or  to  the  industrial  processes.  Medical  supervision 
must  begin  in  dangerous  trades  and  be  extended  later  to  all  in- 
dustries alike. 

There  are  two  forms  of  medical  supervision  of  dangerous 
trades:  (i)  by  states;  (2)  by  individual  owners  of  factories. 

State  medical  supervision  of  factories  has  not  as  yet  become  a 
fundamental  part  of  factory  legislation  except  in  a  very  few 
countries  and  states.  The  only  European  countries  in  which  state 
medical  factory  supervision  is  an  established  fact  are  England 
and  Belgium.  There  is  no  medical  supervision  in  other  European 
countries  except  so  far  that  we  may  here  and  there  find  a  medical 
man  in  the  factory  inspection  department  of  the  state.  England 
has  a  section  of  medical  inspection  attached  to  the  factory  de- 
partment, consisting  of  a  chief  inspector,  with,  from  this  year  on, 
four  assistants;  and  has  also  over  twenty-five  hundred  certifying 
surgeons,  who  may  be  called  medical  supervisors  of  factories, 
in  that  their  functions  are  (i)  certification  of  minors  for  permission 
to  work;  (2)  investigation  of  industrial  accidents;  and  (3)  reporting 
and  investigation  of  occupational  diseases. 

In  Belgium  a  similar  system  is  in  practice,  there  being  a  chief 
medical  factory  inspector  with  three  assistants  and  several  hun- 
dred medicine  aggrege,  whose  functions  are  similar  to  those  of 
the  certifying  surgeons  except  that  they  do  not  certify  the  chil- 


104 

dren  for  admission  to  factories  but  pay  more  attention  to  occu- 
pational diseases  and  to  first  aid  facilities  in  factories. 

In  the  United  Sates,  medical  factory  inspection  is  confined 
only  to  the  States  of  New  York,  Illinois  Mass  achusetts  and  Penn- 
sylvania, New  York  State  having  been  the  first  where  a  medical 
factory  inspector  was  appointed,  Illinois  having  appointed  a 
medical  factory  inspector  three  years  ago,  and  Pennsylvania  and 
Massachusetts  having  introduced  medical  factory  inspection 
during  the  last  year.  New  York  State  has  now  a  separate  divi- 
sion of  medical  factory  inspection  consisting  of  a  chief  and  two 
assistants. 

These  attempts  at  medical  supervision  of  factories  are  still, 
however,  very  crude,  desultory,  insufficient  and  inadequate.  A 
proper  state  medical  supervision  of  factories  means  much  more 
than  the  simple  appointment  of  one  or  more  medical  factory  in- 
spectors attached  to'  the  factory  inspection  department.  It 
means  a  thorough,  comprehensive  supervision  of  every  industrial 
process  or  establishment  which  may  be  included  under  the  designa- 
tion of  dangerous  trades.  Such  a  supervision  is  evidently  im- 
possible with  the  very  small  force  usually  found  in  the  inspec- 
tion departments. 

There  is  really  no  reason  whatever  why  industry  and  the 
captains  of  industry  should  wait  for  the  state  to  establish  a  com- 
pulsory medical  supervision  of  factories.  They  should  do  it  them- 
selves. Indeed,  it  is  pleasing  to  note  that  a  great  many  large 
corporations  and  industrial  establishments  have  already  estab- 
lished a  medical  supervision  of  their  own  and  a  great  many  others 
are  on  the  eve  of  such  a  work. 

Because  the  present  tendency  in  industry  is  to  establish  med- 
ical supervision  and  because  so  many  large  factories  and  indus- 
trial establishments  are  contemplating  such  work,  it  is  timely  to 
discuss  the  purpose  of  medical  factory  inspection,  qualifications  of 
medical  supervisors,  and  to  define  their  functions. 

The  purpose  of  medical  supervision  in  dangerous  trades  is  to 
conserve  the  human  factor  in  industry,  to  preserve  the  health  of 
the  workers,  to  prevent  occupational  diseases,  and  consequently 
to  increase  industrial  and  human  efficiency. 


105 

The  two  most  important  qualifications  besides  medical  educa- 
tion, necessary  for  a  medical  supervisor  in  dangerous  trades, 
are:  (i)  a  knowledge  and  thorough  training  in  industrial  hygiene, 
and  (2)  a  social  viewpoint. 

The  medical  supervisor  in  a  factory  is  intimately  connected 
not  only  with  the  personnel  of  the  industrial  plant,  but  also  with 
the  sanitation,  the  technique  and  the  special  industrial  and  me- 
chanical processes  therein.  Unless  he  has  a  thorough  knowledge 
of  the  industrial  processes  with  which  the  workers  in  the  shop 
come  in  contact,  and  unless  he  is  cognizant  of  the  particular 
dangerous  materials  and  processes  within  the  establishment,  his 
work  in  prophylaxis  will  be  nullified. 

He  should  also  have  a  knowledge  of  sanitation  of  industrial 
plants  and  not  be  like  the  physician  of  a  large  lead  plant  in  New 
York,  who  didn't  know  whether  there  was  hot  water  in  the  plant 
or  not. 

Unfortunately,  our  medical  colleges  have  not  as  yet  included 
in  their  curriculum  a  study  of  occupational  diseases  and  of  indus- 
trial hygiene;  and  we  cannot  blame  the  physicians  who  are  en- 
gaged as  medical  supervisors  for  their  lack  of  technical  knowledge 
of  industrial  conditions. 

The  second  important  qualification  which  I  have  mentioned, 
I  consider  of  great  importance.  The  physician  appointed  as 
medical  supervisor  in  a  factory  must  have  the  proper  social 
viewpoint.  I  do  not  mean  by  this  that  he  should  be  a  socialist 
or  a  member  of  a  labor  organization,  but  he  should  be  imbued 
with  the  principle  of  industrial  justice  and  should  not  regard 
the  worker,  whether  native  or  foreign,  as  an  inferior  being — as  a 
"wop,"  a  "hunk,"  a  "polak."  In  my  investigations  of  a  large 
number  of  factories,  I  have  met  physicians  attached  to  the  fac- 
tories, whose  regard  for  workers  was  so  contemptuous  that  their 
work  of  the  medical  supervision  could  be  of  no  value. 

As  to  the  functions  of  the  medical  supervisor,  these  may  be 
summarized  as  follows: 

1.  Sanitary  supervision  of  the  plant. 

2.  Technical  prophylactic  supervision  of  the  dangerous  processes. 

3.  Preliminary  examination  of  all  applicants  for  work  in  the  factory. 


io6 

4.  Periodical  examination  of  all  factory  workers. 

5.  First  aid  and  treatment. 

6.  Medical  supervision  of  health  of  the  workers. 

7.  Educational  work. 

By  sanitary  supervision  of  the  plant  I  mean  a  general  super- 
vision of  the  sanitary  aspects  of  the  factory:  its  light,  ventilation, 
dust  removal,  the  drinking,  washing  and  bathing  facilities,  the 
methods  of  disposal  of  refuse,  rubbish  and  dirt,  as  well  as  sewage 
and  factory  waste;  and  the  construction,  maintenance  and  condi- 
tion of  the  toilet  and  other  similar  matters.  A  sanitary  super- 
vision involves  not  only  a  general  inspection  but  also  a  daily  rou- 
tine examination  into  all  these  sanitary  aspects  of  the  factory. 

The  technical  prophylactic  supervision  of  dangerous  processes 
is  absolutely  indispensable  if  the  medical  supervisor  of  a  factory 
in  a  dangerous  trade  is  to  consider  his  work  of  practical  value. 
There  are  many  toxic  and  other  materials  which  may  readily  be 
substituted  by  others  less  dangerous;  there  are  a  number  of  pro- 
cesses which,  after  proper  study,  may  be  simplified  and  changed 
so  as  to  lessen  dangers  to  life  and  health;  and  there  are  many 
technical  points  in  industrial  control  that  are  of  great  importance 
to  prophylaxis.  The  engineer,  the  superintendent,  the  foreman, 
have  for  their  functions  the  improvement  of  the  mechanical 
processes,  the  increase  of  industrial  efficiency  and  a  corresponding 
increase  in  production.  The  health  of  the  workers  and  the  pre- 
vention of  diseases  is  no  function  of  theirs.  Hence,  there  should 
be  some  one  in  the  plant  who  should  be  intimately  acquainted 
with  all  the  mechanical  and  industrial  processes  in  the  establish- 
ment and  who  should  supervise  these  processes  with  the  sole 
and  only  purpose  to  lessen  their  dangers  to  health  and  to  prevent 
occupational  diseases. 

It  is  unnecessary  to  dwell  upon  the  imperative  need  of  giving  a 
thorough  physical  examination  to  every  applicant  for  work  in  a 
dangerous  trade.  The  engineer  or  technical  supervisor  of  the 
plant  will  not  for  a  moment  think  it  advisable  to  accept  a  new 
machine  in  the  plant  which  has  not  been  previously  tested  as  to  its 
construction,  etc.,  and  which  has  not  undergone  a  thorough  test 
and  scrutiny.  Why  the  same  practice  should  not  apply  to  every 


new  worker  in  the  factory  is  difficult  to  understand.  There  are 
persons  who  should  not  be  admitted  into  a  factory  where  particu- 
lar dangerous  processes  are  carried  on  or  dangerous  materials 
are  handled.  Therefore,  the  preliminary  medical  examination 
should  be  a  routine  practice  of  the  medical  supervisor  and  should 
be  done  thoroughly  and  scientifically. 

A  periodical  examination  of  every  worker  in  the  plant  is  another 
practice,  the  necessity  of  which  needs  no  explanation.  The  ques- 
tion is  only  how  often  these  periodical  examinations  ought  to  be 
made.  Professor  Teleky  thinks  that  in  lead  trades  a  bi-weekly 
examination  is  necessary.  In  some  plants  this  examination  is 
made  at  too  long  intervals.  Workers  in  very  dangerous  processes 
should  be  examined  at  least  once  a  month,  if  not  every  two  weeks. 
This,  of  course,  aside  from  the  fact  that  all  workers  should  be 
instructed  to  present  themselves  to  the  physician  at  the  slightest 
symptoms  of  sickness.  During  this  periodical  examination  it 
is  possible  for  the  medical  supervisor  to  recognize  the  first  symp- 
toms of  lead  and  other  poisoning  and  to  prevent  further  progress 
of  the  disease  by  changing  the  work  of  the  employee  or  by  giving 
him  a  rest  from  certain  dangerous  processes. 

The  medical  supervisor  in  a  factory  should  also  have  charge 
of  the  first  aid  facilities  in  the  shop.  Such  first  aid  facilities  should 
be  appropriate  to  the  character  of  the  dangerous  materials  handled 
and  processes  carried  on  within  the  shop  and  should  contain  not 
only  the  various  apparatus  for  resuscitation  and  first  aid  treat- 
ment for  injuries,  etc.,  but  also  such  neutralization  materials  and 
special  prophylactic  medicaments  that  may  be  appropriate 
for  each  special  factory. 

The  supervision  of  the  health  of  the  workers  should  not  foe 
limited  to  the  functions  mentioned,  but  should  be  extended  to  a 
general  supervision  of  the  health  of  the  worker,  whether  within 
or  outside  the  factory — to  nutrition,  clothing,  housing,  etc. — so 
that  the  physician  may  be  able  to  come  in  contact  with  the  worker 
even  outside  of  the  shop,  to  recognize  the  elements  of  danger  in 
his  sanitary  surroundings  and  to  give  him  proper  advice  which 
would  lead  to  the  preservation  of  his  health. 


io8 

With  the  above  medical  functions,  however,  the  work  of  the 
medical  supervisor  in  a  dangerous  trade  is  as  yet  not  exhausted. 

The  function  of  the  physician  in  a  shop  in  a  dangerous  trade 
is  not  only  medical  but  also  educational.  He  should  not  only 
examine  and  treat  the  worker,  not  only  inspect  and  supervise 
the  plant,  but  he  should  above  all  endeavor  to  instruct  the  worker 
in  the  risks  and  dangers  of  his  calling,  to  teach  him  the  proper 
methods  of  prophylaxis  and  to  educate  him  in  the  proper  methods 
of  health  preservation  and  of  prophylaxis  of  occupational  diseases. 
Such  educational  activity  would  be  the  climax  of  the  benevolent 
activities  of  the  medical  supervisor  in  the  factory  and  would  be 
the  most  useful  contribution  of  the  medical  men  towards  indus- 
trial efficiency  and  industrial  justice. 


XVI. 

PREVENTION  OF  INDUSTRIAL  ACCIDENTS  AND  SICK- 
NESS BY  SYSTEMATIC  INSPECTION  OF  PLANT 
AND  EMPLOYEES. 

By  H.  W.  JORDAN,   B.S.   in    Chemistry,   Manager   Department  Special   Products  Solvay 
Process  Co.,  Syracuse,  N.  Y. 

The  increasing  state  and  federal  control  of  corporations,  and 
the  trend  toward  socialistic  legislation,  make  it  imperative  that 
employers  maintain  safe  and  sanitary  working  conditions  to  the 
highest  degree.  The  volume  of  such  legislation  is  large  and  its 
spirit  hostile,  because  a  portion  of  employers  have  been  indiffer- 
ent and  have  failed  to  maintain  wholesome  working  conditions. 
The  more  progressive  and  successful  corporations  have  constantly 
regarded  welfare  or  efficiency  work  of  equal  importance  with  pro- 
duction, because  their  experience  has  proven  physical  efficiency 
to  be  as  profitable  as  the  efficiency  of  machinery. 

The  easiest  and  cheapest  way  to  prevent  fires  and  accidents, 
and  to  minimize  sickness,  is  to  maintain  regular  inspections  of 
one's  plant  monthly,  or  at  least  quarterly,  and  to  follow  the  sug- 
gestions for  safety  resulting  therefrom  promptly,  by  removal  of 
the  causes  of  fire,  accident  or  sickness.  The  inspections  should 
be  made  by  executive  employees  and  be  supplemented  by  inspec- 
tion committees  of  operative  employees. 

To  obtain  the  greatest  safety,  annual  inspections  should  be 
made  by  an  independent  inspection  bureau.  The  work  of  these 
trained  inspectors  is  superior,  because  their  experience  is  exten- 
sive and  they  are  not  hampered  by  prejudices  or  by  local  or  per- 
sonal influences,  which  often  warp  the  judgment  of  employee  in- 
spectors. 

The  methods  of  protection  against  fire  and  accident  are  so  thor- 
oughly standardized  that  one  need  not  go  into  their  details  at 
this  time.  The  important  requirement  is  that  regular  inspec- 
tions be  maintained,  that  the  recommendations  be  audited  an- 
nually by  an  independent  inspection  bureau,  and  that  all  reason- 
able recommendations  be  promptly  adopted. 


no 

Emphasis  should  be  laid  upon  the  value  of  neatness  and  good 
housekeeping  throughout  the  plant.  Analysis  of  industrial 
plant  fires  and  accidents,  shows  that  from  30  to  50  per  cent, 
occur  from  heaps  of  rubbish  in  cellars,  in  corners,  or  under  stair- 
ways, and  accidents  from  loose  material  falling,  men  stumbling 
over  tools  left  on  stairways,  projecting  nails  and  splinters,  wrenches 
and  hand  tools  in  ill  repair,  and  from  similar  simple  cases  of  negli- 
gence, or  poor  housekeeping. 

As  city  population  grows  more  dense,  and  as  our  social  structure 
becomes  complex  and  thoroughly  commercialized,  the  individual 
workman  loses  much  of  the  self-reliance  which  characterized 
American  labor  thirty  years  ago,  when  our  highly  organized  and 
intense  industrial  development  began  to  come  into  existence. 

The  working  people  are  at  especial  disadvantage  because  our 
industrialism  has  not  been  accompanied  by  the  development 
of  a  common  school  educational  system  designed  to  train  twentieth 
century  workers  for  twentieth  century  methods  of  earning  one's 
living.  Instead,  we  have  retained  the  early  nineteenth  century 
school  system,  which  focuses  elementary  education  upon  prepara- 
tion for  college.  This  system  has  transformed  our  industrial 
and  commercial  workers,  who  comprise  ninety  per  cent,  of  those 
entering  the  comjnon  schools,  into  one-job  workers,  who  are  mere 
spenders  of  money  and  victims  of  popular  fashion  and  commer- 
cialized amusement,  instead  of  being  versatile  producers  of  the 
necessaries  of  life,  of  thrift,  and  of  contentment. 

Employers  must  cease  to  let  the  social  situation  drift  into  the  com- 
plete commercialization  of  every  human  interest,  which  inter- 
ests a  quarter  of  a  century  ago  centered  in  the  home,  the  church, 
and  in  a  few  simple,  inexpensive  pleasures. 

Employers  must  unite  to  create  a  new  system  of  education 
based  upon  the  principles  evolved  by  Madam  Montessori.  They 
must  help  establish  practical  work  in  child  welfare  and  public 
recreation,  and  they  must  co-operate  in  correcting  the  conditions 
which  make  our  people  thriftless,  inefficient  and  discontented. 

Especially  they  must  institute  practical  methods  of  preventive 
hygiene,  to  reduce  to  a  minimum  the  superabundant  output  of 
tramps,  criminals,  insane,  idiotic,  and  all  other  subnormal,  de- 


Ill 

pendent  and  unemployable  humans,  who  constitute  seven  to  ten 
per  cent,  of  our  city  population;  and  they  must  devote  thought, 
executive  ability  and  money  toward  securing  the  highest  social, 
normal  and  physical  welfare  of  the  working  people,  in  order  to 
transform  the  present  hostility  of  labor  into  efficiency  and  con- 
tentment. - 

The  physicians  who  are  medical  inspectors  for  corporations, 
who  examine  applicants  for  employment  and  attend  the  employ- 
ees disabled  by  accident  or  sickness,  constitute  one  effective  agency 
for  helping  attain  these  social  and  economic  results.  These  physi- 
cians, by  co-operation  with  the  free  dispensaries,  the  associated 
charities,  the  crippled  children's  guilds,  the  probation  officers, 
and  similar  civic  organizations  and  officials,  can  direct  the  ener- 
gies of  such  organizations  to  those  persons  in  the  community 
in  need  of  help  or  restraint,  and  who,  by  reason  of  this  need,  are 
unemployable. 

It  is  only  necessary  that  each  such  physician  note  on  his  indi- 
vidual case  report  to  his  employing  company,  the  social  condi- 
tion and  needs  of  the  patient  and  of  his  family,  if  the  case  involve 
a  visit  to  the  home.  This  information,  reported  daily  by  the 
company  to  the  proper  civic  agencies,  would  bring  these  individ- 
uals and  families  under  observation  and  ensure  their  effective 
social  control. 

This  system  would  ultimately  eliminate  a  large  proportion  of  the 
subnormal,  unemployable  humans,  together  with  the  heavy 
cost  of  their  maintenance,  and  would  raise  the  efficiency  of  all 
working  people,  and  help  mightily  in  reducing  their  unhappiness 
and  discontent. 

A  valuable  part  of  this  work  could  be  done  by  close  attention 
to  the  candidates  rejected  for  employment.  Bach  such  unemploy- 
able person  is  a  civic  problem,  for  physical  or  other  reasons, 
and  is  in  need  of  as  much,  or  more,  attention  than  employees 
who  meet  with  accidents  or  become  ill  during  employment. 

Periodical  inspection  of  individual  employees  may  be  difficult 
to  secure,  although  in  Illinois  and  the  middle  west,  some  corpora- 
tions have  successfully  instituted  such  physical  inspection.  One 
company  in  Chicago  examined  6,800  employees,  and  found  193 


112 

with  tuberculosis,  40  with  advanced  kidney  diseases,  200  with 
communicable  diseases,  and  a  large  proportion  subject  to  anemic, 
nervous  and  other  debilitating  and  incapacitating  disorders. 

At  first  an  annual,  or  semi-annual,  examination  should  be 
offered  without  charge,  to  detect  preventable  diseases  of  the 
major  organs.  It  should  include  examination  of  the  eyes,  mouth, 
nose  and  throat,  blood  pressure,  sputum  and  complete  urine 
analysis.  Cases  of  individuals  in  whom  organic  diseases  are 
prevented  or  retarded  and  whose  effective  lives  are  thereby 
prolonged  should  be  published  by  bulletins  to  all  employees,  in 
order  to  promote  the  work  by  education. 

The  examination  should  be  offered  free,  or  for  a  nominal  fee, 
to  the  families  of  employees,  because  often  the  illness  of  an  em- 
ployee is  the  result  of  conditions  characteristic  to  a  part  or  all 
of  his  family,  so  that  no  material  progress  in  preventive  hygiene 
can  be  made  in  his  case  unless  his  family  be  given  the  benefit  of 
adequate  medical  and  preventive  treatment, 

Group  life  insurance,  which  is  maintained  by  many  progressive 
corporations,  offers  an  excellent  opportunity  for  annual  examina- 
tion of  employees.  In  the  maintenance  of  this  insurance,  no 
employee  would  be  dropped  from  insurance  on  account  of  phys- 
ical unfitness,  after  having  been  admitted  at  the  end  of  one  year's 
continuous  employment,  because  that  is  contrary  to  the  princi- 
ples of  group  insurance,  but  the  annual  renewal  of  insurance  to 
employees  would  offer  an  opportunity  to  make  individual  phys- 
ical examinations,  in  order  to  detect  preventable  diseases  and 
thereby  prolong  the  productive  life  of  employees. 

Group  insurance  granted  to  employees  who  have  completed 
one  year  of  continuous  employment,  and  who  are  then  in  good 
physical  condition,  if  allotted  for  $100  at  the  end  of  one  year's 
continuous  employment,  $200  at  the  end  of  the  second  year, 
and  increasing  to  a  maximum  of  $1,000  for  the  tenth  and  each 
subsequent  year,  and  combined  with  an  annual  physical  examina- 
tion of  each  employee,  is  a  most  powerful  means  of  maintaining 
effective,  continuous  and  contented  employment.  The  annual 
cost  is  $10  to  $15  per  $1,000  of  insurance  in  force,  equal  $6  to  $10 
average  per  person  insured,  or  $4  to  $8  average  per  person  em- 


ployed,  if  employees  who  have  not  completed  one  year's  con- 
tinuous service  be  not  admitted  to  insurance.  In  most  indus- 
tries these  persons  less  than  one  year  in  employment,  constitute 
15  to  25  per  cent,  or  more  of  the  total  employees. 

The  trend  in  industrial  Europe,  as  in  our  country,  is  toward 
governmental  control  of  individual  health  and  welfare.  Those 
corporation  executives  who  have  the  clearest  and  most  pene- 
trating foresight  will  anticipate  and  help  to  modify  radical  or 
socialistic  legislation  by  instituting  practical  health,  welfare  and 
efficiency  work  for  their  employees,  rather  than  delay  such  ac- 
tion until  employers  are  dragged  into  it  by  hostile  legislation. 


XVII. 

RULES  AND  REGULATIONS  IN  OPERATING  PLANTS- 
CARELESSNESS  AND  RECKLESSNESS. 

By  JOHN  B.  LOWMAN,  M.D.,  Surgeon  to  the  Cambria  Steel  Works,  Johnstown,  Pa. 

The  question  of  making  rules  and  regulations  for  an  industrial 
plant  depends  on  what  sort  of  an  industry  it  is.  Rules  for  a  rubber 
factory  or  woolen  mill  will  not  apply  to  a  steel  works  or  an  auto- 
mobile factory.  Such  rules  should  be  adapted  that  will  meet 
the  requirements  of  the  different  industries  by  men  of  experience 
in  their  different  specialties.  There  are  certain  rules,  however, 
that  are  adaptable  to  all  industries.  I  speak  of  the  hygienic 
and  sanitary  condition  of  plants,  the  age  of  labor  employed,  the 
examination  of  the  employees,  the  proper  examination  of  the 
water  supply,  disposal  of  sewerage,  ventilation,  and  the  teaching 
of  the  employees  the  proper  methods  of  living  and  care  of  them- 
selves and  families.  This  should  all  be  under  the  supervision  of 
a  physician  who  has  had  a  practical  experience  in  this  line  and  who 
has  lived  among  the  families  of  the  different  classes  employed  in 
industries,  plus  his  knowledge  in  sanitation  and  hygiene.  It 
has  been  my  good  fortune  to  live  in  an  industrial  city  and  also  to 
be  connected  with  the  Cambria  Steel  Company.  I  shall  speak 
of  this  side  alone.  Steel  plants  employ  all  classes  of  men  who 
are  divided  into  the  skilled  and  the  unskilled  labor.  The  age 
of  employment  varies  from  fourteen  years  (which  is  the  minimum 
according  to  our  State  Law)  up  to  sixty.  The  employees  are  com- 
posed of  most  all  nationalities,  American  and  foreign.  The 
foreign  element  is  principally  composed  of  German,  Slav,  Hun- 
garian, Polish  and  Italian.  Hence,  to  deal  with  all  these  nation- 
alities one  must  be  a  fairly  good  linguist.  These  men  are  employed 
in  many  different  departments.  Mining,  blast  furnaces,  rail 
mills,  machine  shops  and  finishing  departments.  To  look  after 
the  welfare  of  so  many  men  is  by  no  means  a  small  task  and  re- 
quires much  thought  and  hard  work.  It  has  been  shown  that 
the  greatest  number  of  accidents,  seventy-five  per  cent,  take  place 
among  the  unskilled  labor  which  is  composed  of  the  foreign  ele- 


"5 

ment  principally.  The  employer  has  commenced  to  appreciate 
the  efficiency  of  the  employees  because  he  gets  better  returns. 
Somewhere  I  saw  this  statement:  If  physical  efficiency  is  an 
absolute  and  vital  necessity  to  the  working  man,  so  to  him  are 
certain  necessities  for  maintaining  that  physical  efficiency.  Hence, 
many  industries  have  organized  social  and  welfare  workers,  safety 
committees  and  instructors.  We  have  a  safety  department  which 
is  composed  of  experienced  men  who  investigate  the  causes  of 
accidents  and  the  remedy  for  the  same.  The  instructors 
instructing  the  men  in  first  aid  treatment,  and  proper  care  of  the 
injured,  are  under  the  direct  supervision  of  the  surgeon  of 
the  plant.  If  this  is  put  under  trained  nurses  and  instructors 
without  the  supervision  of  the  surgeon  or  medical  man,  many 
times  they  overstep  their  authority  and  treat  cases  and  take 
responsibilities  which  should  come  under  the  direct  care  of  the 
physician.  I  believe  that  too  much  authority  is  given  at  the 
present  time  to  the  social  and  welfare  nurse.  Therefore,  in  my 
plants  I  insist  that  everything  from  the  purchase  of  medical 
supplies  to  the  smallest  article  go  through  the  hands  of  the  medical 
man  and  be  approved  by  him  before  being  used.  In  this  way 
I  know  of  each  article,  where  it  has  been  used,  how,  and  for  how 
long. 

It  has  been  my  good  fortune  to  be  connected  for  twenty  years 
with  the  management  of  their  hospital  for  the  treatment  of 
these  cases.  I  believe  the  Cambria  Steel  Company  was  the  pioneer 
in  looking  after  the  welfare  of  their  men,  and  it  was  not  until 
many  years  after  that  other  industries  saw  the  good  derived  from 
this  branch.  In  fact,  one  of  the  biggest  industries  in  the  United 
States  only  took  up  this  work  not  later  than  ten  years  ago.  So 
quickly  did  they  see  the  good  derived  from  the  same  that  they 
have  spent  thousands  of  dollars  and  perfected  a  most  wonderful 
system  for  the  care  of  the  employees.  In  1887  the  conditions  were 
about  as  I  describe.  The  nearest  hospital  to  our  plant  was  eighty 
miles  away.  If  a  man  was  injured  he  was  taken  to  his  home  where 
the  operation,  if  necessary,  was  performed;  many  times  in  a 
two-roomed  house  with  four  or  five  in  a  family.  There  was  no 
provision  for  the  safety  of  the  employed,  no  proper  dressings, 


n6 

waste,  tobacco,  oil  used  locally  and  whiskey  administered  in- 
ternally until  patient  was  intoxicated.  These  were  the  great 
antidotes  before  the  sensible  first  aid  treatment.  Under  these 
conditions  the  surgeon  had  many  embarrassments  and  compli- 
cations to  contend  with  in  the  care,  treatment  and  operations  which 
he  was  required  to  perform.  No  convenient  or  suitable  place 
to  perform  the  simplest  operation,  no  trained  nurse  to  carry  out 
his  instructions,  in  fact,  all  sorts  of  complications  handicapped 
the  surgeon.  Nothing  clean  or  aseptic,  many  times  the  surround- 
ings being  dirty.  Not  even  a  clean  bandage  or  dressing  to  apply 
to  the  wound  after  operation.  No  prepared  ligatures,  no  absorbent 
cotton,  lint  or  gauze  could  be  bought,  but  all  had  to  be  prepared 
by  the  surgeon  himself  as  the  emergency  required.  No  ques- 
tions were  asked  as  to  the  cleanliness  or  sterility  of  any  dressings. 
It  was  just  such  a  condition  that  induced  the  Cambria  Steel 
Company  in  1887  to  start  and  maintain  a  hospital  and  system 
of  first  aid.  Time  will  not  allow  me  to  go  into  details  and  to  give 
statistics  and  mortality  table  showing  how  accidents  have  de- 
creased. It  is  the  purpose  though  to  try  to  bring  out  the  value 
of  instruction  in  first  aid  and  care  of  the  injured  and  sick.  Over 
this  short  period  of  time  it  has  led  me  to  a  system  which  gives  the 
injured  employee  the  very  best  for  the  relief  of  his  sufferings. 
This  instruction  has  a  far-reaching  effect.  It  is  carried  to  the 
homes  of  the  employees  where  the  families  are  taught  to  improve 
the  conditions  of  their  homes.  This  has  been  impressed  on  me 
more  than  once  by  the  visiting  of  the  afflicted  at  their  homes  after 
their  return  from  the  hospital.  You  see  their  homes  tidied  up, 
nice  clean  bedclothes  on  the  bed,  windows  up  and  good  ventila- 
tion, and  they  have  learned  the  necessity  of  bathing.  I  recall 
one  morning  being  called  to  the  house  of  a  foreigner  where  the 
surroundings  were  at  the  least,  uninviting.  Dirty,  with  the 
windows  down  tight,  foul  air,  the  mother  and  children  in  such  a 
condition  that  I  believe  she  would  have  to  wash  their  faces  to 
tell  one  from  the  other.  I  had  the  man  sent  to  the  hospital  for 
a  badly  infected  leg.  After  a  few  week's  stay  in  the  hospital, 
he  was  discharged.  I  had  occasion  to  be  in  the  vicinity  in  which 
he  lived  and  stopped  in  to  see  him.  To  my  surprise,  conditions 


were  much  improved.  The  home  was  cleaner,  windows  were 
up  and  the  children  were  recognizable.  When  questioned  if  he 
had  had  a  house-cleaning,  he  replied,  ' '  Everybody  wash  and  clean 
every  day,  feel  good  like  hospital."  I  merely  mention  this 
as  one  of  many  of  the  good  results  that  come  from  this  work. 
When  we  look  back  before  the  days  of  first  aid  and  think  of  the 
many  limbs  that  were  sacrificed,  the  many  stiff  joints  and  crippled 
men,  many  of  whom  you  see  sitting  around  the  works  yet,  and 
compare  with  the  present,  the  advance  for  the  safety  and  care  of 
the  employees  has  been  most  rapid.  The  sacrifice  of  a  limb 
nowadays  many  times  means  a  defeat  for  the  surgeon.  This  has 
been  brought  about  by  the  intelligent  instruction  in  first  aid 
among  the  working  men.  The  primary  dressing  means,  in  many 
cases,  the  life  or  future  usefulness  of  the  injured.  To  demon- 
strate by  practical  experience  the  good  results  from  the  care  of 
the  injured,  the  Company  built  houses  for  the  men  and  encouraged 
them  by  small  payments  to  buy  their  homes.  I  believe  there  is 
no  better  way  to  improve  social  conditions  among  industrial 
workers  than  by  encouraging  them  to  own  their  own  homes.  They 
then  take  pride  in  their  little  home  and  become  encouraged  to 
prevent  many  conditions  and  diseases  seen  in  tenements.  It 
has  been  my  experience  in  talking  to  many  men  who  for  years 
did  not  know  how  to  buy  a  house  and  lot  and  so  drifted  along  any 
way  spending  all  they  made.  When  once  shown  and  encouraged 
how  to  do  so,  they  have  saved  and  provided  a  home  for  themselves 
and  families.  Many  systems  as  to  the  rules  and  regulations  of 
the  sick  and  injured  are  in  force,  each  year  being  perfected  by 
past  experiences.  I  shall  not  speak  of  the  many  laws  in  the  differ- 
ent cities  as  to  factory  instruction  and  labor  commissions  but 
confine  the  rules  and  regulations  to  that  which  has  been  in  force 
in  our  plants.  The  following  is  a  re'sume'  of  a  system  to  encourage 
the  men: 

To  get  everyone  thinking  about  safety  and  to  promote  the  safety  habit, 
it  has  been  decided  to  form  safety  sub-committees  in  our  different  depart- 
ments, on  the  plan  outlined  hereinafter. 

Each  sub-committee  will  be  composed  of  two  or  three  men  who  have  been 
in  the  employ  of  the  Company  not  less  than  a  year.  The  members  of  the  com- 
mittees will  be  selected  by  the  Superintendents,  and  will  serve  three  months, 


n8 

the  first  appointees,  however,  to  serve  two  or  three  and  four  months,  so  that 
the  terms  of  service  on  the  committees  will  overlap  and  give  newcomers  the 
benefit  of  the  previous  committeemen's  experience.  Inspection  will  be  made 
Saturday  afternoons  at  least  once  during  each  month  by  the  committee  in  a 
body.  While  on  inspection  duty,  men  of  the  safety  committee  will  be  paid 
full  rate,  if  day  workers,  or  allowed  their  average  hourly  earnings  for  the  week, 
if  piece  workers.  Safety  committeemen,  whether  on  inspection  or  not,  are 
asked  to  report  anything  and  everything  they  see  about  the  plant  they  think 
unsanitary  or  dangerous  or  likely  to  cause  someone  to  be  hurt.  If  they 
think  of  some  way  to  make  safe  the  place  or  thing  they  report,  suggest  it,  but 
make  the  report  anyway.  It  may  be  someone  else  can  think  of  a  way  to  cor- 
rect the  trouble  should  the  person  reporting  it  be  unable  to  do  so. 

Reports  and  recommendations  will  be  made  on  forms  provided  for  the  pur- 
pose, and  signed  by  each  member  of  the  committee.  All  such  recommenda- 
tions will  be  delivered  to  the  office  of  the  Superintendent  of  Department, 
who  will  note  thereon  whatever  comment  he  has  to  make  regarding  the  recom- 
mendation, and  transmit  same  to  General  Manager's  office  with  daily  Break- 
down Report,  when  it  will  have  consideration  by  the  Central  Safety  Committee. 

All  safety  committees  are  to  report  anything  that  they  think  dangerous 
wherever  found  throughout  the  plant  where  their  daily  duties  may  take  them. 
All  employees  are  invited  to  call  to  the  attention  of  the  Safety  Committee 
members  in  their  Departments  anything  they  can  suggest  that  will  likely 
save  someone  from  getting  hurt.  It  will  be  the  duty  of  the  Safety  Committees 
to  report  guards  that  are  not  in  place,  or  neglect  of  men  to  avail  themselves 
of  safety  appliances  of  any  kind  provided  for  their  protection.  In  case  of  any 
accident  in  their  department,  involving  loss  of  time  on  the  part  of  the  injured 
man,  the  safety  sub-committee  is  to  furnish  written  report  to  the  General 
Manager  within  twenty-four  hours  of  such  an  accident,  stating  nature  and 
cause  of  accident,  and  how,  in  their  opinion,  similar  accidents  can  be  guarded 
against  in  future. 

At  intervals  the  Central  Safety  Committee  may  have  the  sub-committee 
inspect  departments  other  than  those  where  they  are  usually  employed. 

We  wish  to  make  this  plant  clean,  safe  and  sanitary,  but  we  cannot  do  it 
without  the  cooperation  and  assistance  of  every  man  who  works  here.  The 
Company  is  doing  all  it  can  to  prevent  accidents  but  there  will  be  maimed 
hands  and  feet  and  blind  eyes  unless  every  man  is  careful  of  his  own  safety 
and  the  safety  of  his  fellow  men.  If  you  know  that  a  thing  is  dangerous,  don't 
let  it  go  until  you  or  another  gets  hurt — report  it  at  once.  If  you  see  a  new 
man  taking  chances,  warn  him.  You  would  willingly  contribute  to  the  help 
of  a  disabled  man's  wife  or  family,  yet  it  is  a  thousand  times  better  to  prevent 
that  man  from  becoming  disabled. 

In  answer  to  a  letter  written  by  me  to  the  first  aid  men,  I  re- 
ceived the  following : 


U9 

Referring  to  our  conversation  regarding  the  safety  work  at  our  plant, 
I  am  handing  you  herewith  several  notices  which  are  posted  throughout  the 
different  departments. 

We  have  received  to  this  date  one  hundred  sixty-one  suggestions  from  these 
safety  sub-committees,  the  greatest  number  of  which  we  consider  very  good 
and  have  been  approved  by  the  central  safety  committee.  I  would  say  that 
out  of  the  total  number  of  suggestions  made,  less  than  six  have  been  rejected. 
We  find  that  the  men  appointed  on  these  safety  sub-committees  are  rather 
proud  of  the  honor  of  serving  and  take  great  interest  and  an  active  part  in  the 
work.  Each  member  of  the  committee  is  furnished  with  the  safety-first  button. 

We  are  endeavoring,  as  rapidly  as  possible,  to  place  suitable  guards  over 
all  belts  and  gears  and  at  every  point  where  we  think  there  is  the  least  possible 
danger  of  a  man  meeting  with  an  injury.  We  are  also  conducting  a  vigorous 
campaign  to  try  to  break  up  the  practice  of  repair  men  permitting  loose,  boards 
or  blocks,  in  which  there  are  protruding  nails,  lying  about  the  floor  or  ground. 

We  are  now  making  up  a  list  of  different  operations,  also  ways  of  handling 
material,  and  when  this  list  is  completed  we  expect  to  have  photographs  taken 
showing  the  dangerous  and  safe  way  of  performing  operations  or  handling  the 
material. 

As  soon  as  possible  after  an  accident  occurs,  i.  e.,  after  the  injured  person 
is  properly  cared  for,  a  thorough  investigation  is  made  and  a  poster  giving  the 
name  of  injured  person,  nature  of  injury,  details  of  how  the  accident  occurred 
and  how  same  could  have  been  prevented  is  placed  on  bulletin  boards:  first 
at  the  main  entrance  to  works  and  later  in  the  department  in  which  the  accident 
occurred.  Should  an  accident  or  injury  be  prevented  by  any  of  our  safe 
guards,  the  use  of  goggles,  glasses,  or  any  of  the  safety  devices  provided, 
the  details  connected  with  same  are  written  up  and  posted  for  the  benefit 
of  the  men.  Also,  should  any  person  be  injured  and  it  is  found  that  the  injury 
could  have  been  prevented  by  the  use  of  safety  devices  which  have  already 
been  furnished,  the  details  connected  with  this  injury  are  posted. 

We  are  working  along  the  lines  of  sanitation,  it  also  being  the  duty  of  the 
safety  sub-committees  to  report  any  condition  of  uncleanliness  found  in  any 
department.  We  have  installed  in  our  pattern  shop  a  modern  lavatory  which 
we  think  is  appreciated  by  men  in  the  department.  We  have  also  just  com- 
pleted in  our  steel  foundry  a  lavatory  fitted  with  stools,  urinals,  individual 
wash  bowls,  shower  baths  and  lockers.  The  men  in  this  department  have 
apparently  fallen  in  with  the  idea.  A  great  number  of  our  Moulders,  Core 
Makers,  and  Dry  £loor  men  now  come  to  work  wearing  new  clothes,  making 
the  change  to  their  working  clothes  after  reaching  the  plant. 

In  addition  to  this,  each  department  has  its  first  aid  team  with 
an  experienced  instructor  employed  at  the  plant.  Twice  yearly 
a  competition  drill  is  given  with  prizes  for  the  best  team.  This 
stimulates  interest  among  men  and  has  brought  the  most  remark- 


120 

able  results.  By  this  method,  the  infection  in  the  past  ten 
years  at  the  hospital  has  been  reduced  from  five  to  ten  per  cent 
to  one-fourth  and  one-half  per  cent.  As  to  the  health  of  the 
employees,  the  condition  living  up  to  this  must  begin  at  home 
under  the  proper  supervision  of  the  physician  and  welfare  nurse. 
This,  I  am  sorry  to  say,  especially  among  the  foreigners,  is  hard 
to  do.  A  man  to  retain  the  proper  resisting  power  and  keep  in 
good  health  should  have  the  best  of  home  surroundings.  Good 
food,  ventilation  and  proper  rest.  One  of  the  best  methods  to 
prevent  this  condition  is  by  proper  instruction  of  their  children 
at  school.  This  seems  to  me  an  important  subject.  We  find 
that  the  average  girl  or  boy  leaves  school  before  entering  high 
school  for  the  simple  reason  that  he  derives  nothing  by  going  far- 
ther, as  manual  training,  industrial  trades,  etc.,  are  not  taught. 
By  the  proper  playground  system,  swimming  pools  and  hygiene 
instruction  much  is  being  done  to  improve  the  hygienic  conditions 
of  the  coming  generation.  Many  of  the  foreign  boarding  houses 
are  the  Mecca  of  disease  producing  lung  and  bronchial  condi- 
tions, to  say  nothing  of  the  skin,  venereal  and  other  afflictions. 
Let  us  picture  for  a  moment  the  condition  of  these  houses.  A 
house  with  two  rooms  downstairs,  kitchen  and  front  room.  Possi- 
bly three  upstairs,  ten  by  twelve,  and  one  room  in  the  attic.  The 
front  room  downstairs  being  occupied  by  the  "boarding  Boss" 
and  his  wife,  with  possibly  three  or  four  children.  A  double 
bed  in  each  corner  of  the  rooms  upstairs  occupied  by  eight  men, 
these  men  going  out  to  night  turn  are  occupied  by  eight  coming  in 
from  day  turn.  The  boarding  boss  and  wife  take  care  of  as  many 
as  thirty-eight  to  forty-eight  men.  The  windows  are  always 
down  tight,  the  air  being  stuffy  when  you  enter  these  houses. 
These  men  are  boarded  so  much  with  beer  and  so  much  without. 
Is  a  man  so  housed  in  a  fit  condition  to  use  his  energy  for  twelve 
hours  at  a  time?  This  problem  must  be  settled  by  the  settle- 
ment worker.  Many  industries  have  welfare  men  and  women 
who  go  to  their  homes  under  the  instruction  of  the  physician 
and  instruct  the  families  in  the  proper  ventilation  and  methods 
of  living,  which,  I  am  glad  to  say,  is  bringing  most  brilliant  re- 
sults. One  of  the  first  rules  should  then  be  the  prevention  of  such 


121 


men  with  suspected  bronchial  or  skin  diseases  working  in  plants 
with  other  fellow  members  until  they  have  a  clean  bill  of  health, 
which  leads  up  to  the  proper  examination  of  each  man  employed 
before  going  to  work  which  I  shall  speak  of  later.  After  such  regu- 
lations are  carried  out,  it  is  then  up  to  the  employer  to  make  these 
plants  as  sanitary  as  possible.  I  believe  one  of  the  most  important 
features  is  the  examination  of  every  employee  before  going  to 
work.  He  should  have  a  good  physical  examination  of  his  eyes, 
lungs,  kidneys,  hernia,  skin  eruptions  and  general  physical  con- 
dition. If  found  to  be  deficient,  he  should  be  acquainted  with  the 
facts  and  the  condition  remedied.  I  believe  there  are  many  men 
working  with  defective  vision,  which,  if  corrected,  would  enable 
them  to  have  better  energy  for  work.  If  the  bronchial  condi- 
tions were  looked  into,  we  would  not  have  to  have  so  many 
signs  of  "no  spitting  allowed."  I  believe  this  is  hard  to  carry 
out  thoroughly,  but  in  some  of  the  smaller  plants  it  has  been 
done  with  most  brilliant  results.  It  is  not  proper  for  an  in- 
dustry to  employ  an  epileptic  when  he  is  liable  to  have  an  epi- 
leptic seizure  injuring  himself  or  some  other  employee,  or  a 
man  affected  with  heart  disease  working  at  a  great  height  and 
liable  to  fall,  or  those  afflicted  with  tuberculosis  among  the  body 
of  workers,  etc. 

Dr.  Karnum  of  the  Avery  Company  spoke  before  the  Illinois 
Manufacturing  Company  in  Chicago  as  follows: 

When  the  Avery  Company  was  started  a  year  and  a  half  ago,  three  or  four 
cardinal  principles  were  accepted  as  being  of  equal  advantage  to  the  employer 
and  to  the  employee.  These  cardinal  principles  were  based  upon  our  dealings 
with  the  men  as  individuals.  The  first  of  these  was  that  the  work  of  this  de- 
partment should  be  a  distinct  effort  toward  the  increase  of  two  things  in  their 
widest  sense — productiveness  and  protection.  In  other  words,  a  matter  of 
safety  on  one  hand  and  efficiency  on  the  other,  and  we  believed  that  safety 
efforts  should  begin  with  the  man,  rather  than  with  the  machine,  not  that  we 
belittle  in  any  way  the  machine  side  of  it.  We  have  our  safety  inspectors, 
and  we  believe  we  have  corking  good  ones,  but  we  do  believe  that  you  can't 
have  safety  without  safety  men.  You  can't  make  good  cylinder  teeth  unless 
you  have  good  material,  and  likewise,  you  can't  make  good  cylinder  teeth 
unless  you  have  good  men  to  make  them.  You  can't  have  a  safe  shop  without 
safety  devices,  but  on  the  other  hand,  you  can't  have  a  safe  shop  with  all 
your  devices  unless  you  have  safe  men.  Another  of  our  cardinal  principles. 


122 

was  that  we  should  accumulate  the  greatest  possible  amount  of  information 
that  could  be  acquired  concerning  employees,  individually  and  collectively, 
because  of  the  value  and  advantage  this  data  might  give  us  in  our  effort  to 
get  at  the  truth  concerning  any  matters  that  might  arise.  Another  of  those 
cardinal  principles  and  one  that  we  have  harped  upon  not  a  little,  is  one 
that  has  become  sort  of  a  slogan  at  the  Avery  Company,  and  that  is  that  "The 
Company  cannot  profit  unless  the  men  profit  first." 

The  Medical  Department  was  installed  a  year  and  a  half  ago,  and  since 
that  time  very  little  has  been  said  of  the  physical  examination  of  the  employees. 
Instead,  we  talk  about  the  medical  supervision  of  employees,  which  you  will 
readily  see  is  a  very  large  field,  of  which  the  physical  examination  is  but  one 
little  corner.  Since  the  establishment  of  this  department,  not  only  have  we 
examined  physically  every  man  who  was  in  the  employ  of  the  Avery  Company 
at  that  time,  but  we  have  examined  every  new  man  before  he  went  to  work. 
We  found,  it  is  true,  a  few  men  who  made  some  noise,  and  sputtered  around 
a  bit,  but  those  men  of  whom  I  have  a  number  distinctly  in  mind,  are  the  very 
fellows  who  are  now  boosting  the  hardest  for  what  we  are  doing.  Withal, 
the  opposition  did  not  amount  to  much.  A  few  minutes  straight  talk  settled 
the  whole  matter,  and  every  man  was  examined. 

It  is  a  fact,  though  the  men  were  not  told  of  it,  that  no  man  already  in  the 
company  was  to  be  discharged  on  account  of  his  physical  condition. 

If  a  man's  condition  was  not  compatible  with  the  work  he  was  doing,  he 
was  put  at  something  else.  We  believe  that  the  men  already  in  the  employ 
of  the  Avery  Company  deserve  protection,  and  we  have  worked  very  hard 
to  protect  them  from  undesirable  applicants. 

A  man  comes  to  the  plant  looking  for  employment.  The  head  of  the  Em- 
ployment Department,  who  also,  by  the  way,  is  working  on  the  same  plan  of 
.getting  the  greatest  possible  amount  of  information  concerning  these  men, 
individually  and  collectively,  talks  over  with  him  the  work  he  has  been  doing 
and  what  he  can  do,  and  if  this  individual  seems  to  fit  the  requirements  of  some 
given  requisition  that  he  has,  he  sends  him  out  to  the  foreman  of  that  depart- 
ment. The  foreman,  if  he  decides  the  applicant  is  desirable,  returns  him  to 
the  Employment  Department.  The  Employment  head  or  one  of  his  as- 
sistants goes  over  the  shop  rules  with  the  man,  fills  out  his  application  for  em- 
ployment, which  goes  still  further  with  the  matter  of  acquiring  information 
getting  a  lot  of  history  of  a  nature  that  might  be  called  industrial  history  in 
contradistinction  to  the  medical  history  which  is  taken  later. 

If  the  head  of  the  Employment  Department,  in  the  course  of  this  history, 
taking,  discovers  anything  that  makes  the  man  seem  unsafe  or  undesirable, 
he  goes  no  further.  If  not,  he  sends  him  into  the  physicians.  We  have 
three  physicians  on  our  staff,  two  of  whom  work  each  morning  with  from  four 
to  six  assistants.  The  first  part  of  the  morning's  work  is  the  dressing  of  acci- 
dent cases  in  order  that  the  men  may  be  sent  to  work  at  their  usual  time,  and 
then  we  get  to  the  physical  examinations.  A  rather  comprehensive  but  in  a 


123 

manner  concise  history  is  taken  as  to  the  man's  previous  health,  accidents, 
injuries,  and  habits,  and  then  the  examination  is  made.  He  is  weighed  and 
measured,  and  his  temperature  taken.  His  chest  is  examined,  his  lungs 
and  heart  are  gone  over  with  special  care.  His  abdomen  and  genito-urinary 
tract  are  examined,  including  a  urine  analysis.  His  ears  are  examined  and 
his  hearing  is  tested.  The  condition  of  his  nose,  throat,  mouth,  teeth  and  gums 
is  noted.  His  muscular  system,  glandular  system,  extremities  and  reflexes 
are  all  gone  over  thoroughly.  There  are  in  all  one  hundred  and  ten  items  in 
the  examination  of  every  man,  to  say  nothing  of  a  large  space  left  for  general 
remarks  and  recommendations,  and  sometimes  this  space  is  entirely  filled  out. 
This,  we  consider,  is  a  little  more  comprehensive  and  a  little  more  searching 
as  to  physical  details  than  the  average  old  line  life  insurance  examination. 

The  first  question  that  naturally  arises  concerning  this  is  the  matter  of 
its  expense  and  next  would  be  what  could  possibly  be  the  use  of  such  elaborate- 
ness in  this  examination.  I  could  not  possibly  answer  these  questions  better 
or,  if  they  were  in  the  nature  of  criticisms,  defend  our  system  better  than  to 
go  over  with  you  the  advantages  we  think  we  are  getting  out  of  the  work  that 
we  are  doing.  One  is  unconsciously  in  the  habit  of  figuring  out  advantages 
•of  work  of  this  sort  from  the  standpoint  of  the  employer  on  one  hand  and  from 
the  standpoint  of  the  employee  on  the  other,  but  when  you  come  to  figure  out 
the  results  of  this  medical  supervision  of  employees,  it  is  a  pretty  hard  matter 
to  know  just  exactly  on  which  side  of  the  fence  to  put  some  of  these  things. 
•Some  of  them  are  really  just  as  much  to  the  advantage  of  the  men  as  they  are 
to  the  advantage  of  the  company. 

For  there  is  another  side  to  this  question  that  must  not  be  overlooked  and 
that  is  the  mental  side,  for  a  workman  is  by  no  means  a  mere  physical  ma- 
chine. In  the  future  we  are  going  to  hear  a  great  deal  more  about  the  psy- 
chology of  accident  prevention  than  we  have  heard  in  the  past,  and  I  think 
this  is  well  worth  while. 

It  is  a  very  nice  thing  to  wander  through  a  factory  and  have  the  safety 
inspector  point  out  all  the  numerous  guards  and  safety  devices  that  have  been 
installed  and  we  appreciate  these  things,  but  we  are  trying  hard  not  to  lose 
sight  of  the  fact  that  first  of  all  comes  the  man  with  his  physical  condition 
and  his  mental  attitude,  and  after  that  comes  the  machine  with  its  safety 
devices.  Then,  there  is  another  of  these  two-sided  advantages  that  we  must 
consider,  and  that  is  the  matter  of  fitting  the  man  to  his  job.  We  have  been 
hearing  a  great  deal  of  late  upon  this  subject  in  lectures  and  in  magazine  arti- 
cles where  men  are  selected  for  various  kinds  of  work  according  to  the  estimate 
of  them  from  their  handwriting,  or  their  complexion,  or  their  type  of  physi- 
ognomy, and  we  at  the  Avery  Company  are  heartily  in  favor  of  this.  We  are 
in  favor  of  anything  that  gives  us  added  information  concerning  a  man,  but 
we  believe  that  the  physical  and  mental  side  are  vastly  more  important  than 
the  temperamental.  A  man's  temperament  as  interpreted  by  his  complexion 
may  make  some  difference  as  to  what  work  he  may  do,  but  we  believe  that 


I24 

whether  he  has  epilepsy  or  heart  disease  makes  more  difference  as  to  what 
work  he  should  do.  This  work  is  conducted  as  a  unit  by  the  various  branches 
of  the  department  and  the  numerous  conferences  that  occur  between  the  head 
of  the  Employment  Department  and  the  examining  physicians  as  to  the  availa- 
bility or  advisability  of  a  given  man  for  a  given  job  is  a  proof  of  that.  Time 
after  time,  following  one  of  these  conferences,  a  man  is  shifted  from  the  work 
that  he  applied  for  to  something  else  with  which  his  condition  is  more  com- 
patible. 

Another  of  the  advantages  is  the  elimination  of  undesirable  applicants. 
We  maintain  that  the  men  who  are  already  at  work  are  entitled  to  all  the  pro- 
tection that  we  can  give  them.  We  know  from  the  statistics  of  our  own  de- 
partment how  many  and  what  per  cent  are  injured  by  the  fellows  working 
beside  them.  So  we  try  to  eliminate  first  the  physical  unfit — the  men  with 
defective  eyesight,  advanced  tuberculosis,  Bright's  disease,  rupture,  heart 
disease,  venereal  infections,  etc.,  that  will  greatly  reduce  their  efficiency, 
increase  their  own  hazard  or  that  of  the  man  beside  them. 

During  the  years  which  I  have  given  to  the  study  of  this  sub- 
ject I  have  naturally  arrived  at  certain  opinions  which  are  more 
or  less  fixed  in  my  mind  and  I  will,  in  conclusion,  try  and  give 
a  short  summary  of  them. 

Carelessness  and  recklessness  among  industrial  employees  is 
the  cause  of  the  greatest  majority  of  sickness  and  accidents. 
This  is  shown  by  accident  reports  in  our  mills.  Carelessness 
of  the  employees  is  due  to  many  causes.  I  believe  by  far  the  most 
common  is  the  overindulgence  in  alcohol.  It  has  been  for  many 
years  a  by- word  at  the  hospital.  Following  pay-day  we  will 
have  lots  of  accidents.  The  mental  condition  of  the  man  has 
a  lot  to  do  with  such  accidents.  It  is  impossible  to  make  any 
machine  fool-proof  or  to  explain  the  proper  methods  of  living 
and  expect  to  have  them  carried  out,  for  man  is  a  lazy  animal 
at  the  best  and  will  take  many  chances  of  the  shortest  way  to 
do  work,  many  times  taking  his  life  in  his  own  hands.  Men 
who  work  in  high  places  soon  become  more  careless  than  an  ordi- 
nary person  would.  Persons  in  ill  health  and  with  body  de- 
formities working  in  hazardous  places  soon  develop  a  sluggish 
way  of  working.  Foreigners  who  do  not  understand  the  language 
put  in  hazardous  positions  easily  become  frightened  and  cause 
the  injury  of  many  of  their  fellow  employees  through  lack  of 
understanding.  I  believe  carelessness  in  industrial  plants  is  one 


125 

of  the  hardest  conditions  to  remedy  and  only  by  the  elimination 
of  some  of  the  exciting  causes  and  strict  discipline  are  you  able 
to  overcome  them.  In  conclusion,  the  rules  and  regulations 
for  operating  industrial  plants  should  commence  at  the  home. 
By  instruction  in  hygiene  and  right  methods  of  living,  the  en- 
forcement of  temperate  habits,  no  employee  being  allowed  to 
work  with  his  fellow  men  who  had  bronchial,  skin,  venereal  dis- 
eases, or  who  has  overindulged  in  alcohol.  Persons  with  deformities 
or  organic  diseases  must  be  employed  in  positions  where  there  is 
no  danger.  The  proper  examination  of  all  employees  and  a  thor- 
ough understanding  of  rules  for  safety  as  given  by  the  plant. 
Shops  should  have  the  best  system  of  ventilation  possible.  Men 
who  work  in  heat  and  moisture,  when  fatigued  or  prostrated, 
should  have  the  proper  showers  and  air  by  system  of  fans.  All 
departments  should  have  good  lavatories  properly  taken  care  of, 
individual  wash  basins  and  showers  and  the  best  of  drinking 
water.  The  water  should  be  properly  inspected  and  then  only 
drunk  through  individual  drinking  cups  or  bubbling  taps.  In- 
dividual towels.  The  proper  feeding  of  the  employees  is  an  im- 
portant factor  in  plants.  If  it  were  possible  to  do  away  with  the 
old  dinner  bucket  and  establish  lunch  rooms  at  the  works  for  the 
employees,  it  would  many  times  overcome  many  difficulties 
as  to  proper  feeding.  In  conclusion,  I  wish  to  say  that  I  have 
not  undertaken  to  give  rules  for  industrial  plants  but  have  given 
a  re'sume'  of  my  experience  of  what  has  been  accomplished  in  the 
last  twenty  years  among  steel  workers. 


XVIII. 

HEALTH     MEASURES     AFFECTING     FACTORY     EM- 
PLOYEES—SOME REMARKS  ON  THE  MEDICAL 
PHASES   OF  SUCH   LEGISLATION. 

By  J.  E.  TUCKERMAN,  A.B.,  M.D.,  Cleveland. 

From  a  legislative  standpoint  health  measures  may  be  national, 
state  or  local.  The  bulk  of  the  laws  affecting  the  health  condi- 
tions affecting  factory  employees  are  passed  by  state  legislatures. 
It  is  obviously  impossible  for  me  to  touch  upon  all  the  specific 
instances  in  which  legislation  bears  upon  the  question.  Even  so 
seemingly  remote  a  subject  as  the  registration  of  births  and  sta- 
tistics on  trade  conditions  in  general  have  a  bearing  upon  the 
matter. 

Laws  regulating  the  health  conditions  of  factory  employees 
were  first  directed  against  accidents.  But  accidents  are  respon- 
sible for  only  a  part  of  the  morbidity  and  mortality  incident  to 
industrial  occupations.  Dr.  F.  L-  Hoffman1  has  stated  that  in- 
dustrial workers  of  this  country  lose  annually  248,750,000  days 
in  sickness,  representing  a  money  loss  of  $772,892,860 — one-quar- 
ter of  which  is  preventable.  An  analysis2  of  the  situation  in  Ohio 
shows  that  among  the  real  workers  in  shops,  factories,  mines, 
offices,  and  stores,  over  one-half  of  the  deaths,  according  to 
census  figures  for  1910,  were  due  to  preventable  causes.  Of 
these  preventable  deaths  1/7  were  due  to  accidents  and  violence 
and  6/7  to  the  diseases  tuberculosis,  pneumonia,  typhoid  and 
poisons.  For  the  United  States,  the  National  Council  for  Indus- 
trial Safety  estimates  the  number  of  killed  and  injured  in  the  in- 
dustries of  the  United  States  each  year  at  2,o35,ooo.3 

All  laws  having  for  their  object  the  control  of  working  and 
living  conditions,  whether  of  factory  employees  or  touching  the 
matter  of  living  of  the  public  generally,  have  their  medical  side. 
These  laws,  or,  if  you  prefer  to  so  call  them,  regulations,  must  be 
founded  upon  known  medical  facts  and  administered  with  a  full 
appreciation  of  their  sociologic  bearing  upon  the  race.  The 


127 

field  is  one  for  preventive  medicine  and  for  sanitation  rather  than 
for  curative  medicine. 

The  extent  to  which  the  application  of  known  medical  facts  can 
control  the  health  conditions  of  large  bodies  of  men  is  well  shown 
in  the  sanitary  conditions  obtaining  on  the  isthmus  of  Panama. 
Similarly  the  control  of  cholera,  plague,  small-pox  and  yellow 
fever  in  the  Philippines,  Puerto  Rico,  and  Cuba,  are  instances 
of  what  can  be  done  through  military  supervision.  And  now 
we  have  at  hand  the  reports4  of  the  wonderful  results  in  the 
United  States  Army  in  the  control  of  typhoid  fever  by  vaccinating 
against  it.  An  army  of  90,000  men  scattered  through  the  United 
States,  Philippines,  China,  Puerto  Rico,  Cuba  and  Hawaii,  and 
some  12,000  of  them  camped  in  Texas  during  February  of  1913, 
reports  but  three  cases  of  typhoid  fever,  two  of  which  occurred 
in  unvaccinated  recruits.  There  were  no  deaths.  Compare 
this  with  the  best  record  in  any  of  our  large  cities.5  New  York, 
in  1913,  had  7  deaths  per  100,000,  while  a  city  of  100,000 
(the  army  has  90,000  men),  Bridgeport,  Conn.,  had  5. 4  deaths 
per  100,000.  For  the  whole  United  States,  in  1913,  the  death 
rate  was  12.7  per  100,000.  And  the  army  reports  three  cases, 
not  deaths. 

Such  results  can  be  obtained  only  when  experts  in  sanitation 
are  given  full  power  to  apply  the  known  facts  of  medical  science 
and  the  established  methods  of  health  conservation. 

Health  legislation  coming  in  conflict  with  that  which  people 
have  been  wont  to  consider  their  personal  liberty,  we  must  in 
large  degree  depend  upon  education  rather  than  force  for  the  ac- 
ceptance of  efficient  health  regulation.  The  employer,  as  well 
as  the  employee,  frequently  considers  state  interference  trouble- 
some and  unwarranted.  Such  exceptional  conditions  as  those 
under  which  the  medical  and  sanitary  expert  conducts  his  work 
at  Panama,  or  in  the  army,  are  difficult,  in  fact  impossible,  to  be 
established  generally  in  the  states,  with  the  public  attitude 
what  it  is.  The  public  unfortunately  distrusts  experts  and  con- 
siders itself  fully  able  to  judge  what  should  and  should  not  be 
done  in  the  governmental  application  of  medical  science.  In  a 
democracy  the  only  way  to  accomplishment  is  thoroughly  educating 


128 

the  public  to  a  faith  in  and  reliance  on  the  judgment  of  experts. 

This  is  a  long  process,  for  the  public  will  give  its  support  only 
so  far  as  it  can  see  forthcoming  results  from  past  performances. 
Dr.  Isadore  Dyer  says:6  "The  public  is  a  self -constituted  critic 
prejudiced  against  the  profession  and  clamoring  for  demonstra- 
ted achievements,  but  it  is  also  a  great  child  needing  to  be  led 
into  the  ways  of  cleanliness  and  health.  With  the  spirit  of  to- 
day the  public  is  ready  for  education,  and  we  owe  it  to  ourselves 
to  go  more  than  half  way  in  the  effort  to  instruct  it."  It  is  for- 
tunate that  such  proofs  of  the  benefits  of  the  application  of  sani- 
tary science  in  Panama  and  elsewhere  are  at  hand  to  serve  as  ex- 
amples of  what  can  be  accomplished,  and  to  furnish  the  text 
for  popular  education. 

Like  the  public,  being  a  part  of  it,  the  legislator  holds  a  similar 
attitude  of  opposition  but  in  a  more  intense  degree,  toward  ex- 
perts upon  any  matter.  Particularly  is  this  true  when  he  is  asked 
to  give  ear  to  the  medical  expert  or  to  the  profession  at  large. 
Whether  we  will  or  not,  the  medical  profession  has  been  placed 
in  the  attitude  of  a  special  interest  seeking  preferment  at  the 
hands  of  the  legislators.  Despite  the  fact  that  it  has  been  through 
the  efforts  of  physicians  themselves  that  requirements  for  medical 
licensure  have  been  raised  and  despite  the  fact  that  it  is  exceed- 
ingly hard  to  practise  medicine  but  exceedingly  easy  to  practise 
unhindered  most  any  "ism,"  none  the  less  whenever  laws  are 
passed  regulating  the  licensure  of  physicians,  they  are  considered 
of  peculiar  benefit  to  the  physicians  rather  than  to  the  public. 

To  change  the  attitude  of  the  public  and  the  legislature  toward 
the  medical  profession,  it  should  be  our  business  to  point  out 
clearly  that  laws  restricting  practice  to  those  having  certain  qual- 
ifications are  laws  for  the  benefit  of  the  public  and  are  in  reality 
a  restriction  upon  the  individual  liberty  of  the  person  desiring 
to  practise. 

It  should  be  our  business  to  make  it  clear  that  health  boards 
and  boards  of  medical  licensure  are  not  a  part  and  parcel  of  the 
medical  profession,  but  are  agencies  of  the  state  having  police 
power  to  protect  the  public  and  in  prosecuting  their  activities 
are  entirely  distinct  from  the  profession  at  large.  We  should  en- 


129 

deavor  to  bring  about  that  these  bodies  shall  receive  their  funds 
from  state  taxation  and  not  be  hampered  by  inadequate  amounts 
as  are  the  boards  of  licensure  when  limited  to  funds  derived  from 
fees  for  registration  and  fines  from  prosecutions. 

The  profession  should  educate  the  public  away  from  the  idea 
that  the  profession  has  an  axe  to  grind  whenever  medical  legis- 
lation or  legislation  containing  a  medical  aspect  is  under  consid- 
eration. The  profession  should  refuse  to  be  involved  in  lobbying 
for  any  bill,  but  should  be  prepared  and  ready  to  give  advice, 
founded  upon  knowledge  of  their  particular  subject,  on  any  bill 
effecting  directly  or  indirectly  the  health  of  the  public. 

The  laws  prescribing  health  and  sanitary  conditions  for  em- 
ployees are  essentially  matters  for  experts.  Questions  arise  in 
which  the  legislator  and  sociologist  should  have  their  views  tem- 
pered by  medical  and  business  advice.  These  questions  must  be 
broadly  considered  from  many  sides,  otherwise  they  fail  of  their 
purpose  by  being  impossible  of  operation.  A  law  intended  to 
meet  certain  conditions  is  made  to  apply  in  special  instances 
where  it  is  unsuited.  At  the  present  time  hospitals,  and  particu- 
larly small  hospitals,  in  California  are  handicapped  by  an  ill- 
considered  eight-hour  law  for  nurses.7 

The  extent  to  which  laws  go  governing  the  conditions  under 
which  employees  work  is  easily  noted  by  consideration  of  the 
topics  covered  by  laws  of  any  up-to-date  state.  In  Ohio  the  legis- 
lature of  1913  laid  down  four  statutes.  The  first  requires  physi- 
cians to  report  to  the  State  Board  of  Health8  instances  of  occu- 
pational disease;  the  second  empowers  the  board  to  investigate 
industrial  hygiene  throughout  the  state  and  to  inquire  into  all 
work  factors  which  might  in  any  way  deleteriously  influence  the 
health  of  workers;  the  third  provides  that  manufacturers  of  cer- 
tain lead  compounds  shall  make  special  provisions  for  the  pro- 
tection and  welfare  of  their  workers  and  provide  monthly  ex- 
aminations by  physicians  of  all  workers  exposed  to  lead  substances ; 
the  fourth  empowers  the  state  board  of  health  to  investigate 
and  pass  upon  the  advisability  of  employing  minors  in  any  of  the 
health-hazardous  industries  from  which  they  are  not  already 
prohibited. 


130 

Among  the  industrial  health  hazards  enumerated  are  dust, 
dirt,  dampness,  darkness,  devitalized  air,  heat,  cold  and  draft, 
fatigue,  inactivity,  caisson  work,  germs  and  infections,  poisons, 
alcoholism,  and  risk  of  venereal  diseases.  The  extent  to  which 
these  health  hazards  operate  is  seen  by  the  fact  that  a  study9  of  six 
hundred  establishments  in  Ohio  employing  124,000  people, 
shows  56,000  in  hazardous  employments. 

Industrial  insurance  companies  show10  that  3,000,000  people 
have  industrial  illnesses  requiring  a  week's  minimum  layoff  per 
year  in  the  United  States. 

Some  further  idea  of  the  medical  aspect  of  the  conditions  under 
which  factory  employees  work  may  be  gathered  from  some  of 
the  headings  in  a  pamphlet  issued  by  the  Ohio  Departments  of 
Workshops,  Factories,  and  Public  Buildings  and  entitled,  "Laws 
Governing  Factory  and  Building  Inspection." 

Safeguarding  Machinery. 

Inspection  of  Bakeshops  for  Plumbing,  Ventilation,  Washrooms  and  Sleep- 
ing Places. 

Regulation  of  Sweatshops,  Entrances,  Water-closets,  Unlawful  to  Employ 
Certain  Persons. 

Minor  Laws,  Preventing  Employment  of  Children  in  Certain  Occupations. 

Employing  of  Minors  in  Factories,  Age  Limit,  School  Certificates,  Hours  of 
Work,  Meal  Times,  Girls  Not  To  Be  Allowed  to  Remain  Standing, 
Etc.,  Etc. 

Employing  of  Females  in  Sweatshops,  Providing  for  Seats,  Proper  Water- 
closets,  Dressing  Rooms  and  Female  Inspectors. 

Inspection  of  High  Explosives. 

School  Attendance  Law,  and 

Law  Touching  Liability  of  Employer  for  Personal  Injury  to  Employee. 

It  is  not  difficult  to  see  the  medical  aspect  cropping  out  through 
these  topics,  nor  is  it  difficult  to  understand  that  their  sociologic 
and  economic  bearing  must  be  taken  into  consideration  before 
there  can  be  a  proper  adjustment.  The  public  must  be  so  edu- 
cated that  the  employee  shall  expect  healthful  working  condi- 
tions and  the  employer  shall  willingly  provide  them.  There 
should  be  no  idea  of  charity  about  it.  It  is  merely  justice  and 
besides  good  business.  "It  is  five  times  as  much  to  the  interest 
of  the  employer  to  promote  welfare  work  than  it  is  to  the  em- 
ployee." And  whether  he  will  or  not,  the  change  of  public  senti- 
ment is  going  to  force  proper  conditions.  The  New  York  Supreme 


Court  in  a  recent  decision11  has  recognized  that  industrial  insur- 
ance is  a  proper  risk  to  be  placed  upon  an  industry,  just  as  much 
as  disabled  machinery  is  a  charge  against  a  business.  The  main- 
tenance of  health  should  be  considered  a  charge  against  the  in- 
dustry. A  similar  decision  has  recently  been  made12  by  the  Su- 
preme Court  of  Wisconsin  to  the  effect  that  medical  and  sur- 
gical treatment  of  injured  employees  as  contemplated  under  the 
Workmen's  Compensation  Act  of  the  state  is  neither  a  charity 
nor  a  penalty,  but  "a  recognition  of  the  economic  truth  that  such 
expense  is  a  legitimate  element  in  the  cost  of  production  and  should 
be  placed  upon  the  product  as  directly  as  practicable."  We  are 
therefore  already  at  the  point  of  social  development  where  the 
maintenance  of  health  of  its  workers  is  recognized  as  a  just  charge 
against  an  industry.  The  question  of  further  development 
along  this  line  is  not  primarily  a  question  of  laws  but  a  question  of 
education  requiring  the  services  of  experts  in  research  and  publicity. 

Many  of  our  cities  are  coming  to  realize  the  necessity  of  such  a 
department  in  the  city  government,  in  order  that  progress  may 
be  made  along  all  social  lines,  health  included.  In  the  new  Cleve- 
land charter,  adopted  a  year  ago  under  the  Department  of  Public 
Welfare,  there  is  provided  a  Division  of  Publicity  and  Research.13 
The  scope  of  the  provision  is  easily  seen.  It  says: 

Section  98.  The  commissioner  of  publicity  and  research  shall  provide 
for  the  study  of  and  research  into  causes  of  poverty,  delinquency,  crime, 
disease  and  other  similar  problems  in  the  community  and  shall  by  means 
of  lectures,  exhibits  and  in  other  proper  ways  promote  the  education  and  under- 
standing of  the  community  in  those  matters  which  concern  the  public  health 
and  welfare. 

In  the  industries  supervision  of  health  conditions  by  a  physi- 
cian is  essential,  and  this  necessity  is  being  recognized  by  many 
employers,  who  are  voluntarily  establishing  welfare  departments 
in  their  works.14  Several  of  the  large  concerns  in  Cleveland  have 
had  welfare  departments  established  for  some  time.  These  are 
under  the  direction  of  a  physician,  generally  the  surgeon  of  the 
company,  who  is  paid  a  salary  not  merely  to  take  care  of  injuries 
but  primarily  to  advise  as  to  the  health  conditions  under  which 
the  employees  work.  Usually  there  are  associated  with  them 
one  or  more  nurses  whose  duty  it  is  to  be  constantly  upon  the 
ground  and  to  see  that  conditions  are  as  they  should  be. 


132 

This  voluntary  activity  upon  the  part  of  employers  could  never 
have  come  about  except  through  the  force  of  circumstances  and 
the  agitation  for  laws  governing  health  conditions  instigated 
by  the  medical  sociologist.  Such  welfare  work  has,  too,  a  very 
intimate  relation  to  the  future  of  medical  practice.  This  form  of 
service  is  certain  to  increase,  and  the  medical  profession  should 
be  in  a  position  to  advise  such  systems  whether  for  state  or  private 
activity  as  shall  be  equitable  to  all  concerned  from  a  financial 
as  well  as  a  humanitarian  standpoint. 

Nineteen  states,  California,  Connecticut,  Illinois,  Iowa,  Kansas, 
Massachusetts,  Michigan,  Minnesota,  Nebraska,  Nevada,  New 
Hampshire,  New  Jersey,  Ohio,  Oregon,  Rhode  Island,  Texas, 
Washington,  West  Virginia,  Wisconsin,  have  passed  and  have  in 
operation  laws  known  as  Workmen's  Compensation  Acts,  which 
have  for  their  object  the  care  of  the  injured  workmen  as  well  as 
making  awards  for  disability  and  death.  Perhaps  the  best  of 
these  are  those  of  California  and  Ohio,  both  in  their  provision 
for  the  interests  of  the  employer  and  employee  and  their  intent 
to  deal  fairly  with  the  medical  profession. 

In  California  the  state  medical  society  is  awake  to  the  situa- 
tion and  is  working  out  a  method  of  cooperation  between  its 
competent  county  societies  and  the  industrial  commission  such 
that  the  individual  physician  will  be  fairly  compensated  whether 
working  for  the  commission  or  for  some  one  of  the  independent 
accident  insurance  companies.15  In  Ohio  there  has  been  consid- 
erable misunderstanding  and  friction,  although  the  Act  as  passed 
is  more  favorable  to  the  physician  than  that  of  any  other  state. 
This  difficulty,  it  is  hoped,  will  be  eliminated  through  the  activi- 
ties of  an  advisory  committee  which  has  been  appointed  by  the 
state  society  upon  the  request  of  the  Governor  of  the  state  to 
cooperate  with  the  Industrial  Commission  of  Ohio.  The  opera- 
tion of  the  Act  will,  we  are  sure,  be  much  improved  by  subse- 
quent experience. 

It  matters  not  whether  the  attitude  of  the  profession  is  hos- 
tile toward  what  some  may  call  socialistic  and  paternalistic 
activities  on  the  part  of  the  state,  the  profession  may  as  well 
realize  that  this  new  development  of  communal  activity  has  come 
to  stay  because  it  is  an  economic  necessity.  Where  it  is  being 


133 

operated  it  is  proving  to  be  of  distinct  advantage  to  the  injured 
workman  and  the  employer.  The  Industrial  Commission  of 
Ohio,  with  less  than  a  year  and  a  half's  existence,  is  caring  for 
100,000  cases  a  year.  Whether  communal  activity  is  to  be  equit- 
able to  the  physicians  engaged  directly  or  indirectly  in  the  em- 
ployment of  the  state  depends  upon  the  intelligence  and  diligence 
which  the  profession  devotes  to  the  solution  of  the  problem. 

We  are  all  more  or  less  acquainted  with  the  industrial  struggles 
of  physicians  abroad.  More  particularly  do  we  hear  of  the  un- 
fortunate position  of  the  German  practitioner  in  relation  to  the 
sick  societies.  In  our  medical  notes  we  constantly  find  mention 
of  pending  crisis  between  the  German  profession  and  its  insur- 
ance societies.  The  situation  in  England  is  more  recent.  The 
Insurance  Act  effects  20,000  English  physicians  out  of  22,500 
wrho  are  in  general  practice.  Our  latest  reports  show  that  the 
benefit  of  the  Act  to  the  physician  is  still  in  debate.  There 
seems  to  be  evidence  to  show  that  the  physicians  who  have  thus 
become  employees  of  the  government  have  not  suffered  thereby, 
but  rather  are  receiving  more  than  previously  from  the  same 
class  of  work.  Surely  we  in  America  must  not  flatter  ourselves 
that  such  problems  as  confront  the  English  and  German  physi- 
cians will  not  confront  us.  The  economic  forces  are  the  same 
and  whether,  when  the  issue  arises,  the  medical  profession  shall 
receive  proper  recognition  lies  with  the  profession  itself. 

Whenever  the  question  of  industrial  insurance  is  up,  the  atti- 
tude of  the  profession  must  be  one  of  advice.  At  the  same  time 
its  members  should  have  the  dignity  to  insist  upon  proper  con- 
sideration and  compensation  under  the  law  for  the  profession. 
Proper  care  of  the  men  must  mean  capable  physicians  coopera- 
ting with  the  state,  and  they  should  be  adequately  paid.  Nor 
can  the  funds  of  the  state  be  properly  protected  unless  the  physi- 
cians are  capable. 

Proper  awards  to  the  men  are  assured  through  the  activities 
of  their  organizations;  equitable  rates  to  the  employer,  through 
the  activities  of  the  employers  associations;  proper  awards  to 
the  physician  must  in  a  large  measure  depend  upon  the  attitude 
of  the  profession  generally. 

It  is  unfortunate  that,  in  our  professional  activities  in  city, 


134 

county,  and  state,  physicians  have  been  unable  to  distinguish 
between  private  charity  and  public  gratuity,  and  have  allowed 
themselves  to  give  alms  to  cities  and  governments  generally, 
by  doing  work  for  inadequate  returns.  This  condition  of  affairs 
can  be  remedied  only  by  careful  attention  and  endeavor.  Super- 
ficially, the  three  elements,  the  employer,  the  employee  and  the 
physician  seem  to  be  at  cross  purposes  with  each  other  in  the 
economic  struggle — in  fact  they  are  and  must  be  mutually  inter- 
dependent. Tact  and  forbearance  on  all  sides  will  be  necessary 
in  adjusting  this  newer  phase  in  industrial  life  to  the  ethics  and 
economics  of  the  physician.  The  adjustment  must  be  made, 
and  whenever  laws  are  projected  affecting  the  health  of  the  opera- 
tives in  the  industries  they  should  be  given  careful  considera- 
tion and  study  by  the  profession. 

BIBLIOGRAPHY. 

1.  Monthly  Bulletin,  Ohio  State  Board  of  Health,  Vol.  IV,  No.  4,  p.  597, 

April,  1914. 

2.  Ibid.,  Vol.  IV,  No.  4,  p.  516,  Apr.,  1914. 

3.  California  State  Journal  of   Medicine,  Vol.  XII,  No.   2,  Feb.,    1914, 

p.  49.     "Industrial  Accident  Law." 

4.  Journal  American  Medical  Association,  Vol.  LXII,  No.   18,  May  2, 

1914,  p.  1371.     "Antityphoid  Vaccination  in  the  Army  during  1913." 

5.  Journal  American  Medical  Association,  Vol.  LXII,  No.   19,    May  9, 

1914,  p.  1473.     "Typhoid  in  the  Large  Cities  of  the  United  States." 

6.  Texas  State  Journal  of   Medicine,  Vol.  IX,  No.  10,  Feb.,  1914,  p.  137. 

"Preservation  of  Health." 

7.  California  State  Journal   of  Medicine,  Vol.  XI,  No.   12,  Dec.,   1913, 

p.  483.     "The  Eight-Hour  Law." 

8.  Monthly  Bulletin,  Ohio  State  Board  of   Health,  Vol.  IV,  No.  4,  Apr., 

1914,  p.  513.     "Health  Hazards  of  the  Industries." 

9.  Ibid.,  p.  515. 

10.  Ibid.,  p.  517. 

11.  California  State  Journal  of    Medicine,  Vol.  XII,  No.  2,  Feb.,   1914, 

p.  50. 

12.  Journal  American  Medical    Association,  Vol.  LXII,  No.  16,  Apr.  18, 

1914,  p.  1281.     "Medico-Legal." 

13.  Charter  of  the  City  of  Cleveland,  Adopted  July  i,  1913,  p.  38. 

14.  Monthly  Bulletin,  Ohio  State  Board  of   Health,  Vol.  IV,  No.  4,  Apr., 

1914,  p.  520. 

15.  California  State  Journal  of  Medicine,   Vol.  XII,   No.   5,   May,    1914, 

p.  1960.     "Action  of  the  State  Society  on  Industrial  Accident  Work." 


XIX. 

HAPPINESS  AS  A  FACTOR  IN  EFFICIENCY. 

By  WOODS  HUTCHINSON,  A.M.,  M.D.,  New  York. 

I  assure  you  that  I  appear  before  you  on  this  occasion  with  a 
sense  of  presumption  due  to  the  fact  that  I  am  almost  the  only 
one  who  has  no  official  right  to  speak  as  an  expert — no  title  before 
his  name;  simply  a  representativ  of  the  country  doctor  and 
of  the  plain  people.  So,  if  my  remarks  are  trite  or  my  infor- 
mation already  familiar,  I  hope  you  will  overlook  it. 

The  difficulty  in  our  welfare  work  is  that  we  take  ourselves  too 
seriously — too  blank  seriously  as  they  say  in  the  West.  If  we 
would  introduce  pleasure  into  our  scheme  of  life  I  believe  our  work 
would  be  more  efficient  and  our  plans  more  likely  to  be  adopted. 
It  is  all  well  enuf  to  inform  the  laity  how  they  ought  to  live  and 
how  much  better  off  they  will  be  if  they  live  on  u  c.  a  day  than 
$1.10 — which  is  what  most  of  us  live  on.  Considerations  of  that 
kind  do  not  arouse  much  enthusiasm  in  the  breasts  of  the  persons 
for  whom  they  are  intended.  I  merely  want  to  put  forward  the 
good  side  of  happiness  and  see  to  what  extent  we  can  increase  the 
happiness  of  every  individual  in  the  community  and  particularly 
of  the  great  mass  of  the  people.  They  are  the  ones  who  are  not 
represented  and  have  no  say  in  most  of  these  discussions,  and  who 
carry  90  per  cent  of  the  work  and  burden  of  the  day.  We  are 
inclined  to  forget,  in  talking  of  the  workers,  that  most  of  us  are 
in  the  position  of  not  having  to  do  manual  labor  for  our  bread. 
Kipling's  fine  hymn  to  labor  describes  the  widely  different  fortunes 
of  us  upper  class  "Sons  of  Mary"  and  the  worker  "Sons  of 
Martha:" 

"We  have  cast  our  burden  upon  the  Lord 
And  the  Lord  he  has  laid  it  on  Martha's  Sons." 

The  question  then  is  that  of  the  happiness  of  the  worker  and 
of  the  whole  community.  In  the  first  place,  happiness  is  of  great 
value  as  an  index.  If  we  watch  carefully  the  faces  of  workers 
in  a  factory  we  have  a  means  more  sensitiv  than  tests  of  air, 
humidity  and  temperature,  of  telling  whether  or  not  the  factory 


136 

is  being  run  under  wholesome  conditions.  If  the  men,  women  and 
children  at  work  do  not  look  happy,  it  is  a  good  place  to  make  an 
investigation.  We  find  a  parallel  in  the  utilization  of  canaries 
and  mice  in  submarines.  The  moment  they  begin  to  chirp  and 
squeal  we  give  attention  to  the  gases  in  the  air.  Like  the  dear 
old  nurse,  who  when  askt  whether  she  used  a  thermometer  in  the 
baby's  bath,  replied,  "Of  course  not,  I  just  put  the  baby  in,  if 
the  water  is  too  hot,  he  turns  red;  if  too  cold,  he  turns  blue;  and 
then  I  know  what  to  do." 

What  do  we  mean  by  happiness?  That  mental  condition  which 
accompanies  perfect  physical  health.  Those  things  necessary  to 
make  a  person  happy  are  those  that  make  for  vigor  and  efficiency. 
As  we  follow  out  the  normal  impulses  of  the  healthy  human  being, 
I  believe  we  shall  find  this  to  be  an  accurate  statement  of  the  case. 

Eating  is  our  favorite  indoor  sport.  The  good  old  lady  who 
was  askt  what  she  had  enjoyed  most  in  her  90  years  of  life,  replied 
promptly:  "My  vittles." 

Dr.  Bulkley  referred  to  the  tendency  among  the  poor  to  buy 
early  fruit  rather  than  articles  of  the  greater  food  values.  If 
some  of  us  had  to  live  on  the  diet  all  thru  the  winter  that  the 
members  of  the  industrial  class  do,  we  would  begin  to  have  a 
craving  for  something  new  hi  the  spring.  The  mere  matter 
of  an  adequate  number  of  calories  is  not  enuf.  The  food  must 
be  of  such  a  character  as  to  appeal  to  our  appetite  and  to  satisfy 
our  demand  for  variety  and  our  absolute  hatred  of  monotony. 
Diet  may  be  ideal  from  a  laboratory  point  of  view  and  yet  people 
cannot  thrive  and  do  their  work  on  it.  Increast  efficiency  and 
power  to  resist  disease  will  follow  adjustment  of  the  diet  upon  these 
lines. 

There  was  a  time  when  we  thought  something  was  wrong  if 
we  were  too  happy.  We  are  getting  past  that  and  into  the  posi- 
tion of  trying  to  get  everybody  into  the  work  for  which  he  is  best 
prepared.  Some  one  has  spoken  of  the  psychology  of  fitting  people 
to  the  occupation  to  which  they  are  best  adapted.  When  a  man 
is  doing  work  easily  and  doing  it  well,  he  is,  nine  times  out  of  ten, 
happy.  In  carefully  adjusting  the  nature  of  the  individual  to 
the  character  of  the  work,  we  are  promoting  happiness  and 


137 

efficiency.  This  question  should  carry  us  outside  of  that  of  food, 
housing  or  of  occupation.  Lack  of  daylight,  objectionable 
fumes,  dust  and  heat  make  for  inefficiency  and  discomfort  in  the 
same  degree  as  do  the  reverse  for  efficiency  and  happiness.  The 
more  nearly  we  make  the  surroundings  contribute  to  the  worker's 
happiness  the  more  nearly  we  attain  economic  efficiency.  I  think 
the  more  we  approach  the  matter  from  this  viewpoint  and  meet 
the  worker  more  than  half-way,  the  more  will  he  respect  our  phil- 
osophy. 

One  of  the  most  important  factors  in  the  happiness  of  the 
individual  is  the  size  of  his  wages.  We  should  use  our  influence 
to  ensure  that  men  shall  receive  enuf  above  their  absolute  needs 
to  be  spent  in  increasing  their  health  and  vigor.  I  believe  we 
should  go  outside  of  the  factory  and  the  conditions  under  which 
work  is  done,  and  provide  for  wholesome,  rational  methods  of 
recreation  and  happiness  in  the  hours  of  rest.  What  a  man  does 
in  his  hours  of  play  is  not  only  an  index  of,  but  has  more  to  do 
with,  his  moral  status  than  what  he  does  in  his  hours  of  work. 

Quite  unintentionally  on  our  part,  we  have  crowded  ourselves 
and  our  houses  together  and  occupied  every  available  foot  of  space 
until  there  is  no  room  left  for  the  people  to  play.  Dr.  Davis 
spoke  of  the  child  who  had  to  go  before  the  Juvenile  Court  and 
be  sent  out  to  its  farm  before  he  found  a  place  where  he  might 
throw  a  stone  as  far  as  he  could  or  yell  as  loud  as  he  wanted  to. 
That  is  the  sort  of  condition  we  have  produced  in  our  cities.  We 
have  so  crowded  conditions  that  we  cannot  let  ourselves  loose. 

Our  scientific  efficiency  plans  provide  now  for  recreation  cen- 
ters, concert  halls,  etc.,  in  connection  with  our  industries.  This 
ought  to  be  made  a  part  of  our  municipal  system.  There  should 
be  provided  places  where  the  young  could  meet  those  of  their  own 
age  under  desirable  and  wholesome  conditions.  To  provide 
proper  places  for  courtship  is  one  of  the  functions  that  should  be 
taken  into  account  and  one  of  the  most  vital.  Instead  of  the 
highways  and  hedges  or  the  dance  hall  under  objectionable  cir- 
cumstances, there  should  be  wholesome  provision  for  the  young 
people  to  become  acquainted  with  their  life  partners,  and  to 
come  together  for  this  most  important  purpose.  That  which 


138 

strikes  me  as  a  most  admirable  institution  of  the  Latin  civiliza- 
tions is  the  great  public  central  plaza,  which  every  little  town 
has,  to  which  everybody  goes  after  dark,  and  where  the  people 
move  about  or  sit  at  little  tables  or  dance.  The  main  thing  is 
to  walk  round  and  round  and  see  and  talk  to  people.  The 
most  interesting  thing  in  the  world  is  people,  just  people.  If 
we  could  introduce  something  of  this  sort  into  our  cities  and  towns, 
I  believe  it  would  do  more  than  almost  anything  else  to  reduce 
social  disease,  immorality  and  inefficiency.  The  amusement 
question  is  one  of  the  most  vital.  I  believe  the  two  things  that 
have  done  most  in  the  last  15  years  to  raise  the  moral  standard  of 
the  youth  of  our  country  are  the  "movies"  and  the  tango.  I 
believe  the  "movies"  should  be  installed  in  every  school  house 
and  in  every  church.  If  we  will  give  heed  to  the  amusements  of 
the  community  we  shall  do  more  than  by  almost  any  other  means 
to  improve  the  health,  raise  the  moral  tone  and  increase  the  happi- 
ness of  the  people. 


XX. 
INDUSTRIAL  INJURIES:  TREATMENT. 

By  W.  L.  EsTES,  A.M.,  M.D.,  Director  and  Physician  and  Surgeon-in-Chief  of  St.  Luke's 
Hospital,  So.  Bethlehem,  Pa. 

The  Employers'  Liability  Acts  which  have  been  passed  in 
twenty-four  states1  and  the  dictates  of  Industrial  Commissions 
in  many  other  states,  have  finally  brought  industrial  establish- 
ments to  a  very  general  installation,  and  the  enforced  use,  of 
safety  measures  and  devices. 

Sporadically,  so  to  speak,  American  manufacturing  establish- 
ments, for  a  number  of  years,  tried  to  profit  by  the  remarkable 
results  accomplished,  especially  by  the  German  establishments, 
and  adopted  many  of  the  devices  shown  in  the  foreign  commer- 
cial museum  exhibits,  but  their  well  intended  efforts  were  in  most 
instances  frustrated  by  the  employees  themselves,  who  refused  or 
neglected  to  use  the  safety  devices  placed  about  their  machines. 

Now  that  the  statute  law  requires  protection  and  holds  the 
employers  responsible  for  the  safety  of  their  work  people,  these 
safety  devices  are  generally  installed  and  their  use  by  the  em- 
ployees is  required. 

The  report  of  the  United  States  Steel  Corporation  for  the  last 
fiscal  year,  states: 

Our  Accident  Prevention  Work  has  reached  a  high  point  of  efficiency. 
Nevertheless,  experience  and  careful  observation  suggest  improvements 
from  time  to  time  and  they  are  promptly  made.  Effort  is  now  being  directed 
toward  teaching  the  workmen  habits  of  caution,  making  watchfulness  against 
dangers  to  themselves  and  their  fellows  a  matter  of  constant  attention.  It 
has  been  necessary  to  overcome  recklessness  and  disregard  of  dangers  which 
had  come  to  be  treated  as  customary  risks  of  the  trade  against  which  the 
men  would  not  take  any  precautions,  to  teach  them  that  taking  risks  will 
not  be  permitted. 

The  cost  of  safety  work  in  1913  was  $660,593.00. 

Serious  accidents  per  1000  employees  are  now  38:/4  per  cent,  less  than  in 
1906,  when  this  work  was  first  taken  up  by  the  corporation.  This  means 
that  2,273  men,  who  might  have  been  injured  under  earlier  conditions,  were 
saved  from  serious  injury  during  the  year.2 

It  is  evident  that  industrial  accidents  are  many  fewer  and  they 


140 

are  likely  still  to  be  reduced  as  experience  and  the  law  require- 
ments shall  be  further  enforced. 

Notwithstanding  all  these  measures  of  care  and  protection 
human  beings  suffer  so  many  lapses  of  attention  and  responsi- 
bility that  there  must  always  be  expected  in  the  United  States 
a  large  number  of  injuries  in  the  large  number  of  establishments 
crowded  with  intricate  machinery  driven  at  ever-increasing  speed. 
Systematized  efforts  to  prevent  injuries  must  apply  not  only  to 
safety  devices  to  protect  the  operatives  from  the  machines  them- 
selves, but  also  to  the  disposition  of  the  operatives'  hours  of 
work,  to  their  physical  conditions,  and  to  their  habits. 

PREVENTION  OF  ACCIDENTS  BY  RULES  FOR  THE  PERSONNEL  OF  THE 

EMPLOYEES. 

(a)  Hours  of  Continuous  Labor. — It  is  a  well  attested  fact  that 
serious  accidents  are  much  more  apt  to  occur  to  an  individual 
workman  when  his  perceptive  faculties  and  his  alacrity  are  blunted 
and  delayed  by  weariness.  The  majority  of  serious  accidents 
therefore  naturally  occur  during  the  last  hours  of  a  man's  work, 
or  when  he  has  by  sleeplessness  or  worry  or  both  combined 
markedly  exhausted  himself. 

Prolonged  periods  of  labor  should  on  this  account  not  be 
permitted  or  required  of  men  working  about  dangerous  machines. 

Naturally  the  danger  is  greatly  multiplied  when  a  large  number 
of  men  do  overtime  machine  work,  or  have  unreasonably  long 
periods  of  labor  required  of  them. 

To  quote  again  from  the  report  of  the  United  States  Steel 
Corporation  (this  corporation  employs  the  largest  aggregate 
number  of  workers  in  the  United  States,  hence  observations, 
experiences  and  conclusions  from  this  corporation  ought  to  be 
especially  applicable  and  valuable) : 

From  our  investigations  of  the  subject,  it  is  believed  that  the  twelve-hour 
day  is  not  physically  detrimental  to  the  men,  because  the  work  is  intermittent, 
and  for  the  further  reason  that  the  introduction  of  machinery  has  eliminated 
most  of  the  arduous  physical  labor.  In  fact,  those  departments  in  which 
the  eight-hour  day  prevails  are  probably  more  exhausting  in  their  demands 
upon  the  men  physically  than  the  twelve-hour  shifts,  owing  to  the  continuous 
nature  of  the  employment.3 


Certainly  not  more  than  twelve  hours  a  day  for  intermitting 
labor  and  not  more  than  eight  hours  for  persistent  labor  seems 
right  in  order  to  conserve  the  wide-awake  attention  and  care 
which  is  required  to  prevent  accidents. 

(b)  Physical  Examinations  Should  Be  Required  of  Employees 
Who  Manage  Dangerous  Machinery. — For  many  years  railroads 
have  recognized  the  necessity  of  physical  examinations  to  pre- 
vent the  employment  of  and  to  weed  out  unfit  employees.  This 
seems  almost  equally  necessary  and  proper  in  regard  to  other 
industrial  occupations  which  are  hazardous,  especially  when 
dangerous  machines  may  be  managed  by  physically  unfit  per- 
sons. 

Not  so  much  color  blindness  but  defects  in  refraction  and  ac- 
commodation in  the  eyes  of  employees  may  serve  to  make  them 
unfit  to  manage  or  to  be  about  dangerous  machines. 

Serious  heart  lesions  which  may  readily  bring  about  syncope, 
or  any  organic  ailment  of  a  persistent  and  serious  nature  which 
may  suddenly  reduce  the  individual  to  helplessness,  should  abso- 
lutely disqualify  a  man  for  employment  about  dangerous  machines. 
Persons  subject  to  epileptic  seizures,  or  those  who  may  give  way 
to  hysterical  attacks,  have  no  place  about  dangerous  machines. 

Men  addicted  to  alcohol,  who  either  daily  or  at  longer  intervals 
use  alcohol  to  excess,  should  not  be  employed  about  dangerous 
machines.  A  little  while  ago,  an  intelligent  leader  among  a 
community  of  Slavs,  told  me,  the  men  are  accustomed  to  drink 
alcohol  and  the  cheapest  commercial  alcohol,  too  (denatured 
spirits).  Besides  the  mental  and  moral  injury  inflicted  these  men 
soon  have  their  stomachs  inflamed  and  in  a  short  time  they  are 
practically  wrecks  physically,  and  absolutely  unreliable  men- 
tally. 

It  is  remarkable  that  industrial  establishments  have  not  yet 
been  convinced  that  tremendous  gain  in  efficiency  would  result 
if  their  employees  were  selected  by  careful  physical  examination 
by  a  competent  person  and  the  unfit  weeded  out. 

Perhaps  the  necessity  of  safeguarding  what  has  hitherto  been 
so  cheap  in  this  country  but  which  is  becoming  commercially 
and  legally  of  some  small  account,  human  life,  will  induce  managers 


142 

of  industrial  establishments  to  appreciate  the  normal  human 
beings  of  good  habits  at  their  proper  value  as  preventers  of  acci- 
dents and  conservers  of  other  human  lives. 

(c)  Treatment  of  Injuries. — I.  First  aid:  Modern  enlighten- 
ment should  require  in  every  large  industrial  establishment  that 
at  least  a  number  of  the  superior  employees  shall  have  received 
good  training  in  elementary  first  aid  work,  and  the  theory  of  in- 
fection of  wounds,  and  the  measures  to  prevent  infection. 

These  foremen  should  be  named  and  be  regularly  appointed 
as  the  heads  of  the  first  aid  department  in  the  works. 

In  a  large  establishment  each  shop  or  department  should  be 
equipped  with  a  well  selected  kit  for  first  aid,  and  should  have 
a  regular  dressing  station,  of  easy  access,  but  protected  from  the 
dust  and  grime  of  the  mill.  The  foreman  designated  as  first  aid 
man  in  each  department  should  have  charge  of  this  dressing  sta- 
tion and  should  render  first  aid  to  all  injuries  in  his  department. 
Each  large  establishment  should  be  provided  with  proper  stretchers 
and  if  it  is  necessary  to  transport  injured  men  any  distance 
it  should  have  one  or  more  ambulances.  It  is  far  better  for  the 
mills  to  have  their  own  ambulances  than  to  trust  to  an  ambulance 
from  even  a  near-by  hospital,  for  the  service  will  be  much  quicker, 
and  with  a  trained  attendant  for  the  ambulance,  and  trained  first 
aid  dressers,  the  service  will  be  equally,  if  not  more,  efficient. 

2.  Permanent  treatment:  Serious  injuries  should  as  soon  as 
practicable  be  transported  to  a  good  hospital  and  receive  perma- 
nent treatment  as  required  by  modern  methods. 

It  is  hardly  necessary  for  this  paper  to  enter  into  any  discussion 
of  the  vexed  question  of  hospitals  conducted  by  the  mills,  or  whether 
it  is  best  for  mills  to  send  their  injured  people  to  a  general  hospital 
not  under  the  direction  and  control  of  the  mills. 

When  there  is  no  good  hospital  in  the  community  unquestion- 
ably the  mills  should  provide  one  for  the  proper  treatment  of  its 
employees.  General  hospitals  in  a  community  may  readily  ob- 
tain the  services  of  one  or  more  of  the  best  surgeons  in  the  com- 
munity. Some  of  the  best  men,  however,  would  hesitate  to  ac- 
cept the  position  of  contract  surgeon  of  an  industrial  establish- 
ment. 


143 

Where  the  wards  and  facilities  of  a  well  equipped,  first-class, 
general  hospital,  situated  not  too  far  away,  may  be  had,  it  is  best 
both  in,  the  interests  of  the  patient  and  the  mill  to  send  the  in- 
jured employees  to  this  hospital.  Unquestionably,  too,  the  mill 
should  pay  the  hospital  a  proper  daily  per  capita  remuneration 
for  this  service. 

The  sociologic  effect  of  the  two  kinds  of  hospitals  are  matters 
of  no  small  account.  This  phase  of  the  question  cannot  fully 
be  discussed,  but  some  points  ought  to  be  mentioned. 

An  industrial  establishment  which  owns  and  manages  a  hos- 
pital naturally  directs  not  only  the  economic  affairs  of  the  institu- 
tion, but  manages  the  essential  features  of  the  treatment,  by 
furnishing  or  not  furnishing  the  best  up-to-date  equipment  for 
operations  and  after-treatment. 

The  prevalent  atmosphere  of  these  institutions  is  apt  to  be 
commercial  and  may  lack  the  desirable  humane  considerations 
which  should  prevail  in  a  hospital.  Daily  per  capita  cost  is  apt 
to  stand  ahead  of  annual  efficiency  in  restoring  life  and  limb. 

Industrial  hospitals,  too,  restrict  the  educational  advantages 
of  the  staff  and  of  a  community  which  should  belong  to  a  good 
hospital;  "the  material"  is  not  available  for  clinical  study  and 
exhibition  except  for  a  very  few  men.  Thus  the  hospital  loses 
a  double  stimulus  for  advancement  of  method  and  improvement 
of  technique,  namely,  the  incentive  of  teachers  and  leaders,  and 
the  prickling  up  of  intelligent  thoughtful  inquiry  and  doubt  of 
the  pupils.  The  physicians  of  the  community  are  not  at  liberty, 
nor  can  the  surgeon  in  charge  freely  invite  his  colleagues  to  avail 
themselves  of  the  clinics  and  operations. 

Well  taken  and  carefully  recorded  notes  should  be  preserved, 
indexed  and  filed  in  the  hospital,  also  a  well  devised  "follow  up" 
system  should  be  employed  in  every  hospital,  in  order  to  estab- 
lish the  values  of  certain  lines  of  treatment,  methods  of  proce- 
dure or  operations,  and  to  standardize  proper  results  of  treatment. 
In  this  way  the  officers  of  the  hospital  and  those  of  the  mill  would 
know  whether  or  not  a  proper  measure  of  efficiency  was  obtained 
by  the  surgeons  in  the  hospital,  and  the  surgeons  could  compare 


144 

their  results  with  those  of  other  hospitals  for  their  own  encour- 
agement or  stimulation. 

Results  could  be  standardized  so  that  medico-legal  investiga- 
tions might  have  reliable  data  upon  which  to  base  conclusions 
as  to  degree  and  time  of  disability  which  ought  to  follow  as  a 
proper  result  from  all  the  ordinary  injuries. 

By  this  system  speculative  suits  would  be  very  much  less  fre- 
quent, and  the  just  demands  of  the  permanently  incapacitated 
man  would  be  much  more  apt  to  receive  early  and  adequate 
recognition. 

BIBLIOGRAPHY 

1 .  Bulletin  of  the  United  States  Bureau  of  Labor  Statistics,  whole  number 
126. 

2.  Statement  as  to  wages,  hours  and  other  conditions  of  labor  among 
employees  of  the  United  States  Steel  Corporation,  and  subsiduary  companies. 
1914  Report.     Taken  from  the  report  of  Special  Committee. 

3.  Ibid. 


XXI. 

THE  RELATION  OF  THE  MEDICAL  PROFESSION  TO  THE 

WORKMEN'S  COMPENSATION  ACTS  IN  THE 

UNITED  STATES. 

By  FREDERICK  L.  VAN  SICKLE,  M.D.,  Olyphant,  Pa. 

The  evolution  that  has  taken  place  in  the  industrial  world 
in  the  past  twenty  years  has  brought  about  many  changes  in 
industrial  conditions,  in  conservation  of  the  laboring  classes, 
in  relation  to  their  health,  sanitation  and  general  welfare,  owing 
to  a  better  realization  of  the  monetary  value  of  human  life  and 
health,  to  industry. 

This  evolution  has  rapidly  changed  the  laws  of  European 
countries  and  has  invaded  the  United  States  in  rapid  succession. 

BRIEF   HISTORY   OF   WORKMEN'S   COMPENSATION   ACTS. 

In  the  4th  special  report  of  the  Commission  of  Labor,  issued 
in  1893,  under  the  title  of  "Compulsory  Insurance  in  Germany," 
was  the  first  report  published  in  this  country  on  the  subject  of 
workman's  insurance.  At  that  time  compensation  for  industrial 
accidents  had  been  established  by  law  in  two  countries  only — 
Germany  in  1884  and  Austria  in  1887,  the  third  country,  Norway, 
not  following  until  1894. 

Since  the  publication  of  this  first  report,  the  development  of 
the  legislation  providing  for  workmen's  compensation  for  in- 
dustrial accidents  in  Europe  and  throughout  the  world  has  been 
extremely  rapid;  in  fact,  it  may  be  doubted  whether  any  subject 
of  labor  legislation  has  ever  made  such  rapid  progress  or  gained 
so  general  an  acceptance  for  its  principles  throughout  the  world 
in  so  brief  a  period.  Legislative  summaries  show  that  forty-one 
foreign  countries  (including  all  European  countries,  except  Turkey) 
have  introduced  some  form  of  workmen's  compensation  for 
industrial  accidents,  all  of  which,  while  showing  great  variations 
in  the  industries,  cover  the  amount  of  compensation  provided 
and  the  methods  by  which  compensation  payments  are  secured, 
recognize  the  principles  of  compensation  as  distinguished  from 
the  older  idea  of  employers'  liability,  previously  accepted  in  the 


146 

civil  law  of  Continental  Europe,  as  well  as  in  English  and  American 
law. 

In  the  United  States  what  might  be  called  the  period  of  investi- 
gation and  education  began  somewhat  late  as  compared  with 
European  countries,  but  since  that  beginning,  investigation  and 
study  have  been  followed  by  legislative  action  with  great  rapidity. 

The  first  American  state  commissions  were  appointed  in  New 
York,  Wisconsin  and  Minnesota  in  1909,  and  legislation  followed 
in  New  York  in  1910,  in  Wisconsin  in  1911  and  Minnesota  in 
1913.  Within  this  period,  beginning  with  1903,  27  commissions, 
not  including  one  federal  commission,  have  been  appointed 
to  consider  the  subject  of  compensation  and  compensation  legis- 
lation has  been  enacted  in  23  states. 

With  this  remarkable  development  of  compensation  legisla- 
tion in  the  United  States  and  throughout  the  world  within  so 
short  a  period,  it  would  seem  especially  desirable,  to  study  and 
compare  the  various  provisions  already  in  force,  to  serve  as  a 
guide  to  new  or  amendatory  legislation. 

It  became  evident  in  the  United  States  some  years  ago  that 
the  old  employers'  liability  system  was  inadequate  and  wasteful 
to  a  degree  and  wholly  unsuited  to  the  present  industrial  conditions. 
As  a  result,  some  safe  and  sane  method  of  distributing  assistance 
to  injured  workmen  was  established  through  commissions  in  each 
state  and  the  introduction  of  workmen's  compensation  acts, 
which  dealt  more  favorably  with  the  question  at  issue. 

The  United  States  Bureau  of  Labor,  in  Bulletin  No.  78,  esti- 
mates the  total  mortality  from  accidents,  in  the  United  States 
among  adult  wage  earners,  to  be  between  30,000  and  35,000  an- 
nually, and  the  non-fatal  accidents,  half  of  which  occur  in  industrial 
establishments,  to  be  approximately  2,000,000  each  year.  This 
waste  of  human  life,  misery  and  hardship  which  follow  the  maim- 
ing and  disabling  of  wage  earners,  injured  while  in  pursuit  of 
flieir  trades  and  callings  and  for  which  under  the  old  liability 
laws  only  a  small  percentage  received  any  compensation  what- 
ever, constituted  an  indictment  against  our  civilization  and  which 
these  new  compensation  acts  seek  to  remedy. 

The  fundamental  principle  both  in  Europe  and  in  the  United 


147 

States  is  that  the  expense  of  injuries  incidental  to  modern  industry 
should  be  treated  as  a  part  of  the  cost  of  production,  workmen  to 
be  compensated  for  industrial  accidents,  not  as  in  prior  conditions 
on  the  basis  of  the  liability  of  the  employer,  but  on  the  fact  of 
injury.  The  desired  result  is  that  prompt  and  reasonable 
compensation  is  insured  to  all  injured  workmen  and  the  only 
exceptions  being  such  cases  as  are  caused  by  serious  and  wilful 
misconduct  of  the  workmen  themselves. 

Liability  acts  under  the  common  law  defense  were  that  the 
employee  was  negligent;  that  the  injury  was  caused  by  the  negli- 
gence of  a  fellow-employee,  or  that  the  employee  had  assumed 
the  risk  of  the  injury — any  or  all  of  which  unjustly  kept  the 
injured  workman  from  recovering  damages,  and  which  were 
abolished  by  the  introduction  of  workmen's  compensation  acts. 

Under  these  new  laws  the  employee  comes  automatically  within 
its  provisions,  unless  he  gives  notice  to  his  employer  that  he 
elects  to  stand  upon  his  common  law  rights,  in  which  case  his 
employer  continues  to  be  fully  protected  by  the  common  law, 
and  the  injured  workman  recovers  damages  only  through  delay 
and  uncertainty  of  the  courts.  If  the  employer  elects  not  to 
come  under  these  new  acts,  the  injured  employee  has  the  right 
to  proceed  against  him  with  these  three  common  law  defenses, 
previously  available,  removed,  and  with  the  possibility  of  the 
injured  employee  collecting  heavy  damages,  the  sole  question 
in  such  proceedings  being  the  negligence  of  the  employer. 

THE  RELATIVE  VALUE  OF  SUCH  PROVISIONS  TO  THE  WORKMEN  OF 
THE   STATES.      WILL    "SAFETY   FIRST"   BE   IMPROVED? 

The  relative  value  of  such  provisions,  as  workmen's  compensa- 
tion acts,  to  the  workmen  of  the  United  States,  have  depended 
and  will  depend  much  upon  the  equity  and  fairness  with  which 
they  are  framed  and  applied.  The  demands  for  these  laws  do 
not  come  from  employees  alone,  for  wage  earners  have  been 
very  slow  in  times  past  to  protect  themselves,  either  by  insurance 
or  through  a  demand  for  compensation  after  injury. 

Employers  also  recognize  the  real  need  for  laws  which  would 
not  only  give  reasonable  compensation  to  the  injure  workman 


148 

but  would  tend  ultimately  to  bring  about  the  adoption  of  safety 
devices,  which  would  reduce  substantially  such  injuries,  and  the 
corporations,  many  of  which  have,  previous  to  this  law,  provided 
such  compensation  without  enforcement,  have  been  of  material 
assistance  in  aiding  legislation  in  the  several  states  of  our  country. 

One  of  the  greatest  organizations  of  manufacturers  in  the  country 
in  national  convention  recently  adopted  regulations  which  de- 
clared : 

"That  the  present  system  of  determining  employers'  liability 
is  unsatisfactory,  wholly  wasteful,  slow  in  operation,  antagonistic 
to  harmonious  relations  between  employers  and  wage  workers," 
and  that  some  effective  means  of  automatically  providing  relief 
for  the  victims  of  industrial  accidents  and  their  dependents  should 
be  provided  in  order  that  waste  might  be  eliminated,  litigation 
and  friction  reduced  to  their  minimum  and  the  requirements  of 
justice  conserved. 

Wisconsin  in  its  introduction  of  its  workmen's  compensation 
act  of  1913,  says: 

The  objects  of  the  Compensation  Act  are  as  follows:  ist,  To  furnish 
certain  prompt  and  reasonable  compensation  to  the  injured  employee;  2nd, 
To  utilize  for  injured  employees  a  large  portion  of  the  amount  of  money 
wasted  in  the  present  liability  system;  3rd,  To  provide  a  tribunal  where 
disputes  between  employers  and  employees  in  regard  to  compensation  may 
be  settled  promptly,  cheaply  and  summarily;  4th,  To  provide  means  of 
minimizing  the  number  of  accidents  in  industrial  pursuits. 

The  present  slogan  in  all  the  industrial  world  is  "SAFETY 
FIRST,"  and  it  would  seem  from  the  study  of  compensation  acts 
that  perforce,  manufacturers,  mine  and  mill  owners,  industrial 
corporations  and  all  interested  in  the  great  problems  of  manu- 
facturing and  industrial  life,  would  seek  greater  safety  for  those 
who  are  the  life  blood  of  their  industries — then-  workmen. 

It  has  been  shown  in  the  reports  of  several  of  the  states,  in 
the  short  time  they  have  been  operating  these  legal  measures, 
that  the  number  of  accidents  has  been  reduced,  that  the  severity 
of  the  injuries  has  been  somewhat  mitigated,  and  that  further 
improvement  will  be  as  rapid  as  is  the  introduction  of  compensa- 
tion laws  in  the  remaining  states  of  our  Union,  where  they  have 
not  been  adopted. 


149 

In  the  report  of  the  Illinois  Commission,  which  was  prepared 
prior  to  the  introduction  of  the  compensation  law  in  the  legis- 
lature, they  make  the  following  statement: 

The  state  of  the  mining  industry,  one  of  the  largest  industries  of  the  state, 
leads  the  commission  to  the  conclusion  that  the  adoption  of  the  scheme  of 
compensation  would  affect  a  change  of  but  1.6  cents  per  ton  of  coal  mined, 
to  meet  the  necessary  expenditures.  As  to  the  direction  of  this  expense, 
it  is  said — should  this  prompt  the  exercise  of  extra  care,  as  the  commission 
confidently  anticipates,  only  a  portion  of  this  increase  would  be  utilized  for 
the  purpose  of  compensation,  the  remainder  going  into  the  plant  in  additional 
safeguards  and  conveniences. 

It  can  readily  be  seen  by  this  comment  of  the  commission, 
that  legislation  aimed  to  protect  workmen  would  aid  materially 
in  causing  manufacturers,  coal-mining  industries  and  the  like, 
to  make  their  plants  as  safe  as  human  invention  can  make  them, 
thereby  minimizing  the  number  of  avoidable  accidents  due  to 
unprotected  machinery,  carelessness  of  fellow-workmen  about 
unprotected  places,  and  the  more  strict  enforcement  of  rules 
and  regulations  whereby  accidents  may  be  avoided. 

THE    APPARENT    DISSIMILARITY    IN    THE    PROVISIONS    AS    FOUND    IN 
THE   DIFFERENT   STATES. 

The  dissimilarity  in  the  provisions  as  found  in  the  different 
states  now  having  compensation  laws  has  been  commented 
upon  by  commissions  appointed  to  investigate  the  laws  and  to 
make  reports  to  legislatures  in  states  not  having  adopted  such 
measures. 

The  commission  in  Colorado  made  no  attempt  to  draft  a  law, 
inasmuch  as  the  examination  made  of  the  statutes  of  the  other 
states,  showed  such  wide  divergence,  that  no  conclusion  was 
reached  as  to  the  type  to  be  recognized.  The  commission  was 
impressed  with  the  importance  of  uniformity  of  legislation  on 
the  subject,  but  felt  that  none  of  the  existing  state  laws  were 
adopted  to  the  industrial  conditions  of  Colorado. 

It  was  agreed  that  a  compensation  law  should  be  enacted  and 
that  it  should  be  applicable  to  all  productive  employments, 
and  that  there  should  be  some  plan  by  which  compensation  pay- 
ments would  be  guaranteed.  It  was  recommended  that  more 


150 

study  and  investigation  be  given  to  the  subject  before  any  bill 
was  drafted,  reference  being  made  to  the  fact  that  all  laws  of  this 
type  are  of  recent  enactment  in  this  country  and  that  it  took 
1 6  years  to  unify  the  laws  of  Germany  on  the  subject. 

From  a  table  compiled  by  the  Commission  of  Labor  Statistics, 
Senate  Document  No.  336,  December  23,  1913,  we  find  the  fol- 
lowing comparisons  of  workmen's  compensation  insurance, 
as  per  table  hereto  attached. 

An  inspection  of  the  tables  above  referred  to,  discloses  consider- 
able diversity  in  the  matter  of  systems  adopted,  whether  com- 
pensation or  insurance,  compulsory  or  elective;  if  insurance, 
whether  under  state  control  or  with  approved  companies,  and 
whether  at  the  sole  cost  of  employer  or  cooperative.  The 
majority  of  states  elect  that  the  employer  shall  stand  the  cost 
of  the  compensation.  The  industries  covered  find  most  of  do- 
mestic and  agricultural  labor  excluded,  while  some  only  designate 
classes  of  extra  hazardous  employment.  Most  of  the  industries 
specify  that  where  machinery  is  employed  and  that  where  more  than 
five  workmen  are  on  the  pay-roll,  a  compensation  must  be  granted. 

In  the  system  of  compensation  as  to  whether  acceptance  of 
the  system  or  rejection  of  the  same,  we  find  that  this  ranges 
from  an  individual  filing  of  such  workmen  of  an  acknowledged 
writing,  as  in  the  elective  law  of  New  York  State,  or  in  the  absence 
of  formal  rejection,  as  in  a  number  of  other  states. 

In  the  abrogation  of  defense  under  the  elective  system  in  most 
states,  it  is  made  an  inducement,  which  has  been  criticized  as 
<:oercitive,  that  where  employers  refuse  to  come  within  the  pro- 
visions of  the  compensation  law  the  customary  defense  to  action 
for  injuries  shall  not  be  allowed  them.  In  most  cases  the  pro- 
vision is  made  an  alternative  one.  In  some  cases  the  law  applies 
only  to  employers  having  an  excess  of  a  certain  number  of  em- 
ployees. The  abrogation  of  these  defenses  does  not  affect  the 
employers  of  a  smaller  number  of  employees.  The  same  is  true 
also  in  cases  in  which  the  employee  rejects  the  compensation 
system  and  sues  an  employer  who  has  accepted  such  a  system. 

The  importance  of  guaranteeing  payments  has  been  recog- 
nized even  more  widely  than  any  other  provision  that  has  been 


made.  Aside  from  the  guarantees  and  preferences,  as  indicated 
in  the  table,  compensation  payments  are  usually  exempt  from 
execution  and  are  not  assignable  when  in  the  hands  of  the  bene- 
ficiary. 

The  necessity  of  more  provision  of  this  sort,  apparent  on  the 
face  of  things,  is  borne  out  by  the  report  on  the  operations  under 
the  statutes  of  New  Jersey,  in  which  it  is  reported  that  in  a  num- 
ber of  cases  the  benefits  due  workmen  were  not  paid  to  them. 

A  very  important  item  in  the  comparison  of  laws,  comment 
upon  which  has  been  made  by  many  of  the  state  journals  in  states 
where  compensation  laws  exist,  is  Waiting  Time.  Most  of  the 
laws  fix  a  time  during  which  no  compensation  is  payable  imme- 
diately following  the  accident  causing  disability.  This  ranges 
from  6  days  to  2  weeks,  and  for  this  time  no  compensation  is 
allowed  in  most  states  other  than  such  provision  as  is  made  for 
medical  and  surgical  attendance,  and  in  many  of  the  states,  no- 
reference  is  made  to  medical  and  surgical  attendance.  In  a  few 
cases,  however,  if  the  disability  is  prolonged  beyond  a  designated 
time,  benefits  are  payable  for  the  first  week  or  weeks  of  dis- 
ability. The  federal  statute  allows  no  compensation  for  an 
injury  not  continued  beyond  15  days,  but  where  the  injury  con- 
tinues, payment  is  made  from  the  first  day.  This  results  in  the 
denial  of  all  compensation  for  disability  lasting  as  long  as  14  or 
15  days,  but  allows  16  days  full  pay  for  a  disability  of  a  day  or 
portion  of  a  day  beyond  the  waiting  time  fixed. 

There  may  be  a  variety  of  reasons  for  these  differences,  but 
there  is  ground  at  least  for  a  belief  that  the  difficulty  in  enforcing 
a  return  to  work  under  circumstances  that  would  forfeit  all  com- 
pensation when  the  prolongation  of  the  disability,  whether  with 
or  without  serious  extension  of  a  proper  time  for  recovery,  allows 
the  injured  workman  to  secure  full  pay  for  all  the  time  lost,  is 
effective. 

There  is  a  rather  wide  divergence  in  the  amount  of  compensa- 
tion allowed  in  the  different  states,  which  in  all  probability  arises 
from  the  fact  that  conditions  of  wages,  of  the  class  of  work, 
and  the  principles  of  equitive  payment  have  entered  into  the 
construction  of  the  laws  in  different  states,  and  a  wide  discussion 


152 

has  ensued  as  to  the  best  method  of  awarding  compensation. 
This  is  arranged  in  three  classes:  (i)  for  death;  (2)  for  total  dis- 
ability; and  (3)  for  partial  disability. 

In  some  states,  in  addition  to  the  payment  for  loss  of  time  and 
injury,  provision  is  made  for  medical,  surgical,  hospital  and  nurse 
attendance,  and  in  a  large  number  of  cases  for  burial  in  case  of 
fatal  injuries,  as  well. 

The  necessity  for  a  law,  not  excessively  burdensome  to  the 
employer  and  not  unduly  tempting  the  prolongation  of  benefits, 
and  which  affords  reasonable  benefits  to  the  injured  workman, 
so  as  to  prevent  hardships  of  dependents  and  loss  of  the  family 
wage  earners,  is  desirable — all  of  which  have  led  to  a  wide  variety 
of  attempts  to  determine  the  proper  amounts  to  be  awarded. 
It  has  been  said  that  "the  scale,  so  far  as  possible,  should  divide 
the  wage  loss  sustained  by  the  employees  and  their  dependents, 
equally  between  them  and  their  employers." 

We  observe  that  this  is  both  impossible  and  undesirable,  as 
the  contention  has  been  sustained  in  that  the  industries  should 
bear  the  burden  of  expense.  Neither  is  it  tenable  or  desirable 
to -compensate  for  injuries  by  full  rate  of  pay.  Yet  it  must  not 
be  forgotten,  as  was  considered  under  the  common  law  defense, 
to  take  into  consideration  the  pain,  suffering,  inconvenience  and 
extra  expense  borne  by  injured  workmen  and  their  families, 
upon  which  no  money  value  can  be  set. 

The  provision  for  benefits  for  death,  based  on  the  earnings 
of  the  injured  person  in  most  cases,  usually  approximating  3  or 
4  years'  wages,  is  payable  in  installments  ranging  from  50  per  cent, 
to  6o2/3  per  cent,  of  the  weekly  wages.  Minimum  and  maximum 
amounts  for  weekly  payments  and  for  the  total,  in  most  states 
are  allowed.  Children  who  are  beneficiaries  usually  have  the 
benefits  payable  in  their  behalf  cease  on  their  reaching  the  age 
of  1 6.  In  a  few  cases  the  limit  is  18  years.  A  few  states  have 
the  provision  also  that  benefits  shall  not  cease  at  the  ages  named, 
if  the  recipient  is  physically  or  mentally  incapacitated  from 
earning  a  living.  The  re-marriage  of  a  widow  terminates  the 
benefits  in  a  number  of  instances,  although  in  a  few  a  lump  sum 
is  payable  on  re-marriage.  If  the  beneficiary  is  a  widower,  no 


153  •, 

provision  is  made  for  a  similar  allowance  in  case  of  re-marriage. 

The  question  of  permanent  disability  has  always  been  a  very 
difficult  one  to  decide  and  some  states  recognize  the  fact  that 
a  permanently  disabled  workman  is  a  greater  economical  loss 
to  his  family  than  if  he  were  killed  outright  at  the  time  of  the 
accident,  and  allow  in  case  of  permanent  disability  a  larger  amount 
of  compensation  than  in  cases  of  fatal  accidents,  some  continuing 
payment  for  the  full  period  of  the  injured  workman's  life.  In 
every  state  law,  provision  is  made  for  continuing  partial  disability, 
often  by  a  percentage  of  the  wage  loss  occasioned  by  such  dis- 
ability, while  in  a  number  of  states  there  is -a  scale  fixed  by  law 
awarding  weekly  payments  for  fixed  periods  after  specified  in- 
juries, the  payments  being  based  on  the  amount  of  wages  earned 
at  the  time  of  the  injury. 

It  is  noted  that  in  the  legislation  of  the  year  1913,  the  system 
of  providing  a  scale  of  fixed  rates  for  specified  injuries  seems  to 
have  been  in  favor,  and  that  in  amendments  to  earlier  laws  such 
schedules  were  adopted  in  lieu  of  the  percentage  provisions  con- 
tained therein. 

The  schedules  of  periods  of  compensation  adopted  in  the  various 
states  include  generally  the  same  items,  and  it  is  possible  to  tabu- 
late them  so  as  to  afford  a  comparison  of  the  awards  allowed  by 
the  different  states  for  specified  injuries.  In  most  cases,  com- 
pensation is  to  be  continued  for  a  fixed  number  of  weeks,  while 
in  a  few  instances  the  term  is  measured  by  months. 

From  investigation  as  to  the  dissimilarity  of  the  various  acts 
of  states  now  having  compensation  law  and  their  awards,  we 
observe  it  was  necessary  to  prepare  tables  of  disability,  which 
differ  largely  as  to  compensation,  owing  to  the  short  time  in  which 
they  have  been  in  operation  in  the  United  States. 

It  is  apparently  difficult  to  compare  statistics  between  American 
and  European  scales,  owing  to  the  fact  that  European  countries 
have  had  in  operation  in  some  form,  compensation  laws  for  a 
much  greater  length  of  time  than  has  prevailed  in  the  United  States. 
The  tables  as  prepared  by  the  Bureau  of  Labor  Statistics  give  com- 
puted percentages  of  disability  for  specified  injuries  and  are  based 


154 

on  the  schedule  of  compensation  awards  under  the  laws  of  various 
states. 

In  this  we  find  that  we  have  the  nature  of  injuries,  loss  of  arm, 
hand,  thumb,  foot,  leg,  etc.,  and  a  percentage  rate  as  to  the  award 
for  such  injuries.  In  this  table  we  see  a  great  divergence  from 
any  specified  standard,  and  also  from  a  comparison  of  these  tables 
and  those  of  foreign  countries,  it  is  apparent  that  a  greater  award 
is  paid  in  most  of  the  foreign  countries  than  pertains  in  the  United 
States. 

Injuries  to  the  eye  have  received  comparatively  little  attention 
in  American  laws,  decrease  of  visual  incapacity  being  noted  in 
but  one  statute,  while  in  European  practice,  compensation  laws 
have  been  arranged  in  Russia  and  Germany  computing  the  de- 
crease of  disability  due  to  the  weakening  of  the  eyesight. 

While  many  of  the  distinctions  presented  in  these  tables  are 
far  more  elaborate  than  any  yet  in  force,  the  development  of 
a  system  of  compensation  awards  will  necessarily  involve  the 
use  of  schedules  for  the  guidance  of  administrators  of  compensa- 
tion laws. 

California  probably  has  a  more  complete  system  of  worked- 
out  scale  of  percentage  of  compensation  for  physical  disability, 
resulting  from  injuries,  than  any  of  the  states.  In  many  of  the 
states,  but  little  is  said  regarding  such  specified  forms. 

Time  for  notice  and  claim  for  disability  is  noted  in  the  various 
laws,  and  limitations  are  placed  on  the  time  for  giving  notice  from 
10  to  30  days,  and  the  time  limit  for  a  claim  for  injuries  is  from 
6  months  to  2  years.  The  time  for  presenting  a  claim  or  bringing 
action  thereon  appears  usually  to  be  fixed  absolutely  in  all  the 
states. 

The  method  of  settling  disputes  that  arise  owing  to  disability 
and  an  award  for  injuries  in  most  cases  is  left  for  arbitration. 
In  a  large  number  of  states  a  special  commission  or  board  is 
created  to  have  charge  of  the  administration  of  the  law,  and  if 
an  insurance  law,  of  funds  collected  under  it.  In  other  states 
arbitrators  are  chosen  for  the  purpose,  or  any  standing  committee 
of  employer  or  his  workmen  may  take  cognizance  of  disputes, 
while  in  some  states  the  disputes  are  referred  to  the  courts.  In 


155 

all  cases  an  appeal,  sometimes  only  on  certain  phases  of  questions 
involved,  may  be  referred  to  the  courts.  Where  the  courts  are 
charged  with  the  settlement  of  disputes,  it  may  be  provided 
that  proceedings  shall  be  summary  or  that  juries  may  be  dis- 
pensed with  in  such  cases. 

THE  NEED  OF  CODIFICATION  OF  THESE  ACTS,  FOR  THE  BENEFIT  OF 
STATES   PROPOSING  TO   PASS   SIMILAR   LAWS. 

We  observe  from  this  investigation  that  out  of  the  total  num- 
ber of  states  in  the  Union,  but  23  have  in  operation  or  will  have 
by  July  i,  1914,  laws  pertaining  to  workmen's  compensation, 
and  it  can  be  readily  understood  that  from  this  dissimilarity  of 
provisions  in  the  states  now  having  such  laws,  there  is  a  need  of 
codification  of  these  various  acts  and  a  joint  effort  on  the  part 
of  commissions  to  aid  states  proposing  to  pass  similar  laws  in 
getting  them  as  near  uniform  as  it  is  possible  to  do. 

We  might  refer  with  profit  to  the  experience  of  a  stock  insurance 
company,  a  report  of  which  was  submitted  to  the  Industrial 
Department  of  the  State  of  New  York,  and  which  shows  that 
the  laws  of  some  of  the  states  are  indefinite  and  uncertain  as  to 
the  amount  of  compensation  to  be  paid  and  in  what  cases  it  should 
be  paid.  In  order  to  determine  its  liability  the  company  is 
required  in  some  cases  to  appeal  to  an  arbitration  board  or  a 
state  industrial  board.  When  the  liability  of  the  company  is 
determined,  the  benefits  are  promptly  paid.  Any  delay  in  making 
settlements  of  disputes  that  have  arisen  can  in  practically  all 
cases  be  blamed  on  the  failure  of  the  laws  of  the  various  states 
to  clearly  prescribe  the  amount  of  benefits  due  the  workman, 
and  further  many  of  the  laws  do  not  prescribe  the  method  to  be 
adopted  in  computing  the  amount  to  be  paid  in  a  lump  sum 
settlement.  All  such  settlements  must  be  approved  either  by 
a  court  or  by  an  industrial  accident  board,  and  where  such  settle- 
ments have  been  made,  the  proper  procedure  has  been  taken. 

We  find  that  compensation  claims,  especially  those  where 
any  dispute  arises  as  to  the  amount,  are  settled  much  more  ex- 
peditiously  and  satisfactorily  in  states  which  have  industrial 
accident  boards,  whose  duty  it  is  to  approve  the  claim  settle- 


156 

ments.  It  is  the  function  of  members  of  such  boards  to  determine 
the  amount  due  under  the  compensation  law  and  to  issue  rulings 
as  to  their  interpretation  of  its  provisions;  as  members  of  the 
industrial  accident  boards  devote  all  their  time  to  the  subject  of 
workmen's  compensation,  it  is  evident  that  the  ruling  of  such 
a  board  is  of  more  value  than  that  of  an  arbitration  board  selected 
promiscuously.  As  the  injured  workman  selects  one  arbitrator 
and  the  assured  another,  these  two  selecting  a  third,  it  devolves 
upon  such  third  member  in  most  cases  to  decide  the  disputed 
question.  It  is  also  true  that  in  but  few  instances,  if  any,  does 
the  same  arbitration  board  act.  It  is  believed  that  in  all  states 
there  should  be  one  board  or  authority  which  will  make  uniform 
interpretation  of  disputed  questions  arising  under  the  law.  It 
can  readily  be  seen  that  otherwise  the  insurance  companies  or 
arbitration  boards  will  make  different  decisions  as  to  the  benefits 
to  be  paid  on  claims  arising  under  the  same  provisions  of  the  law 
and  a  similar  state  of  facts. 

We  might  further  multiply  the  points  of  dissimilarity  in  the 
various  laws  of  the  states,  but  for  our  present  purpose  it  is  sufficient 
to  say  that  amendments  to  the  laws  having  been  made  within 
the  past  five  years  indicate  that  a  nearer  solution  of  the  problem 
is  being  made,  and  that  the  amount  of  information  now  available 
seems  sufficient  to  warrant  the  preparation  of  an  adequate  law 
to  meet  any  industrial  condition.  The  amount  of  litigation 
that  has  reached  the  courts  of  last  resort,  indicates  the  importance 
of  careful  wording  and  full  provision  to  carry  out  the  intentions 
of  legislatures  in  states  where  laws  are  not  in  force. 

It  might  be  said  that  we  of  the  States  are  not  the  only  ones 
having  difficulty  regarding  the  workmen's  compensation  acts, 
as  reference  to  an  editorial  in  the  New  York  Medical  Journal, 
May  23,  1914,  which  states:  "That  the  bill  now  before  the  On- 
tario (Canada)  legislature  as  to  its  liability  to  make  compensation 
to  its  employees  for  injuries  received  during  employment,  is  in 
its  entirety,  just,  neither  to  the  Province  or  to  the  profession  of 
medicine.  Employers  of  labor  are  to  be  assessed  on  the  wage 
percentage  basis  to  provide  for  an  accident  fund.  The  act 
does  not  make  provision  for  payment  of  surgical  and  medical 


157 

•care,  like  similar    acts  of  other  countries,  and  the  medical  men 
in  Ontario  object  to  its  adoption." 

It  is  suggested  in  this  editorial,  that  physicians  in  the  United 
States  should  watch  the  progress  of  this  bill  among  their  neighbors 
and  follow  their  good  example  in  interesting  themselves  in  this 
matter  of  compensation  for  injury  and  to  let  them  see  that  all 
state  legislation  bearing  on  the  subject  makes  full  provision  for 
the  payment  by  the  employer  of  all  reasonable  medical  and  surgical 
fees. 

THE  RESULT  OF  THE  APPLICATION  OF  THESE  ACTS    TO  THE  MEDICAL 

PROFESSION. 

The  relationship  of  the  application  of  the  laws  pertaining  to 
workmen's  compensation  in  states  now  having  them  in  force 
and  in  states  in  which  they  will  subsequently  become  enforced, 
is  very  close  to  the  medical  profession.  Every  case  of  injury 
or  disability  occurring  under  the  provisions  of  these  acts  must,  of 
necessity,  receive  the  attention  of  some  physician,  and  a  careful 
discussion  of  the  relative  merits  of  these  acts  in  relation  to  our 
profession  will  be  of  material  advantage. 

We  find  in  analyzing  the  provisions  in  the  several  states  now 
"having  compensation  acts,  the  same  dissimilarity  as  in  other 
portions  of  their  provisions.  For  instance,  out  of  the  23  states, 
we  find  a  wide  application  of  medical  and  surgical  provision. 
One  state  gives  medical  and  surgical  aid  for  one  week;  five  for 
two  weeks;  one  for  thirty  days;  one  for  eight  weeks;  three  for 
three  weeks;  one  for  sixty  days;  three  for  ninety  days;  six  do  not 
pay  except  upon  decease  of  employee  leaving  no  dependents; 
two  make  no  provision;  one  gives  reasonable  service;  one  pays 
to  the  limit  of  $150;  one  pays  to  the  limit  of  $200;  one  pays  to 
the  limit  of  $250.  For  medical  examinations  of  employees  at 
request  of  company  $5  to  $10  is  allowed. 

In  many  of  the  states,  fee-bills  have  been  introduced,  which 
give  a  list  of  operations  and  subsequent  hospital,  home  or  office 
attention.  In  this  also,  we  find  a  variety  of  dissimilarity. 

The  question  of  fee-bills  and  remuneration  to  physicians, 
from  the  medical  aspect  of  workmen's  compensation,  has  been 


158 

the  greatest  bone  of  contention  in  states  now  having  this  measure 
in  operation.  It  is,  no  doubt,  no  more  difficult  of  application 
than  is  the  operation  of  the  fee-bill  in  any  county  of  any  state, 
where  men  of  our  profession  have  divergent  views  upon  the  question 
of  what  the  public  should  pay  for  their  services. 

This  same  discussion  upon  the  fees  for  services  to  injured  work- 
men brings  no  greater  difficulty  to  our  minds,  than  what  we  have 
passed  through  in  the  various  states,  with  our  effort  to  create 
uniformity  of  fee-bills! 

California  and  Ohio  have  discussed  this  question  more  fully 
than  other  states,  and  it  seems  that  some  profit  might  be  gotten 
in  considering  the  opinions  of  men  from  these  states. 

In  the  California  State  Journal  of  May,  1914,  in  discussion  of 
the  fee-schedule,  we  find  the  following,  relative  to  the  fee-bill 
as  presented  by  the  Industrial  Commission.  It  says: 

The  fee-schedule  is  not  a  schedule  of  flat  fees  for  all  cases.  It  is  a  list  of 
minimum  fees  appropriate  for  workrren  earning  not  over  $1000  a  year. 

It  does  not  cover  everything;  special  cases  need  special  consideration. 

It  is  not  put  out  as  a  contract  of  flat  fees  for  which  physicians  must  treat 
everybody  injured. 

The  total  amount  received  by  our  members  per  year  will  be  very  much 
more  than  what  they  get  now. 

In  the  California  law,  the  employer  has  the  right  to  call  or 
designate  what  physician  shall  treat  the  injured  person.  When 
the  employer  has  insurance,  this  right  is  transferable  to  the  in- 
surance company.  The  patient  has  nothing  to  say  about  it. 

The  commission  has  very  wide  power  to  adjust  difficulties 
and  differences  that  may  arise,  and  it  is  admitted,  unofficially, 
that  possibly  in  some  instances  the  patient  may  be  permitted  to 
have  something  to  say  in  the  matter  of  his  physician. 

The  commission  states:  "That  the  vast  majority  of  acci- 
dents are  trivial  and  that  the  employed  or  injured  person  is  not 
kept  from  his  work  for  more  than  two  weeks.  For  this  reason 
no  compensation  will  be  allowed  for  that  period  of  time  and  un- 
limited medical  or  surgical  attendance  may  be  provided. 

"The  amount  to  be  paid  to  physicians  for  their  work  should  be 
commensurate  with  the  income  of  the  injured  person;  that  the 
charge  should  be  what  ordinarily  would  be  charged  by  the  doctor 


159 

if  the  patient  had  to  pay  the  bill  himself  and  not  have  it  paid  by 
the  employer  or  the  insurance  company." 

We  now  come  to  the  more  serious  part  of  the  fee-bill,  viz., 
contract  form  of  work.  In  California,  many  physicians  have 
been  asked  to  sign  a  blank  contract  form,  agreeing  to  accept  the 
fee-schedule  and  undertake  to  do  the  accident  work  for  the  com- 
pany, at  their  terms. 

The  State  Insurance  Department  did  not  take  this  course  of 
action  and  has  not  asked  the  physician  to  sign  any  such  contract. 
They  intimate  that  the  fees  which  the  state  will  pay,  will  be,  in 
most  cases,  higher  than  those  indicated  by  the  insurance  com- 
panies. Space  will  not  permit  of  the  introduction  of  these  fee- 
bills,  but  a  few  items  will  give  us  sufficient  data  for  discussion: 

Fractures. 

Femur  or  humerus,  reduction  and  first  dressing $25 

Clavical  or  scapula 15 

Fore-arm  or  leg — i  bone 10 

Fore-arm  or  leg — 2  bones 25 

Patella 15 

Compound  Fractures.    50  per  cent,  additional  to  operation. 

Dislocations. 

Easy,  without  anesthetic 5 

Hip 10 

Operations. 

Hernia,  radical  operation 30 

Amputation  of  finger  or  toe. 5 

Fore-arm  or  arm 25 

Knee  or  thigh 40 

Assisting  at  Operations. 

Major. 10 

Minor. : .  , 5 

Administering  anesthetic 5 

The  real  objection  as  presented  to  the  law  in  most  states  is 
the  inelasticity  of  the  fee-bill,  and  that  where  minimum  fee-bills 
are  given,  the  minimum  will  also  be  the  maximum. 

It  is  contended  by  friends  of  compensation  acts  that  considera- 
tion should  be  taken  of  the  fact  that  where  states,  through  state 
commissions  or  insurance  companies  agree  to  fees  of  physicians, 


i6o 

these  physicians  are  paid  in  entirety,  while  it  is  our  general  ex- 
perience in  surgical  work  that  many  fees  so  earned  are  never 
received  in  general  practice. 

Besides  the  fees  for  operations,  the  fee  for  visit  of  $1.50  and 
office  $1.00  would  absolutely  compensate  in  a  great  majority  of 
cases  in  proportion  to  what  is  ordinarily  received  in  general 
practice. 

Bearing  upon  the  question  of  fees,  it  has  been  stated  that  there 
is  nothing  in  compensation  laws  to  prevent  the  injured  person 
from  suing  the  surgeon  for  alleged  malpractice,  if  he  chooses, 
though  he  may  not  sue  the  employer. 

In  many  of  the  states  we  find  no  plan  has  been  adopted  to 
pay  for  medical  and  surgical  services  directed  by  law.  In  some 
it  is  only  upon  the  death  of  the  patient  that  the  physician  re- 
ceives compensation.  In  other  states,  for  instance,  Minnesota: 

Medical  and  surgical  treatment,  medicine,  medical  and  surgical  supplies, 
crutches  and  apparatus  as  may  be  required  at  the  tin  e  of  the  injury  and  there- 
after during  disability,  not  to  exceed  90  days,  to  cure  and  relieve  from  the  effect 
of  the  injury,  the  same  are  to  be  provided  by  the  employer,  and  in  case  of  his 
inability  or  refusal  seasonably  to  do  so,  the  employer  to  be  liable  for  reasonable 
expense  incurred  by  or  on  behalf  of  the  employee  in  providing  same,  pro- 
vided, however,  the  total  liability  under  this  Section  shall  not  exceed  the  sum 
of  $100  in  value,  except  that  the  Court  may  during  said  period  of  90  days, 
upon  necessity  being  shown  therefor,  require  the  employer  to  furnish  such 
additional  medical,  surgical  and  hospital  treatment  and  supplies  as  may  be 
reasonable,  which,  together  with  any  such  sums  or  relief  therefor  furnished, 
shall  not  exceed  hi  all  $200  in  value. 

Again  we  see  in  New  Jersey : 

During  the  first  two  weeks  after  the  injury  the  employer  shall  furnish 
reasonable  medical  and  hospital  services  as  and  when  needed,  not  to  exceed 
$50  par  value,  unless  the  employee  refuses  to  allow  them  to  be  furnished 
by  the  employer. 

Ohio: 

In  addition  to  the  compensation  provided  for  herein,  the  Board  shall 
disburse  and  pay  from  the  State  insurance  fund  such  amounts  for  medical, 
nurse  and  hospital  services  and  medicine  as  it  may  deem  proper,  not,  however, 
in  any  instance  to  exceed  the  sum  of  $200,  and  the  Board  shall  have  full  power 
to  adopt  rules  and  regulations  with  respect  to  furnishing  medical,  nurse  and 
hospital  services  and  medicine  to  injured  employees  entitled  thereto  and  for 
the  payment  thereof. 


Oregon : 

The  Commission  shall  have  authority  to  provide  under  uniform  rules  and 
regulations,  first  aid  to  workmen  who  are  entitled  to  benefits  hereunder, 
together  with  transportation,  medical  and  surgical  attendance  and  hospital 
accommodations  for  injured  workmen,  at  an  expense  not  to  exceed  $250 
in  any  one  case,  and  to  contract  therefor  in  its  discretion. 

Nebraska : 

During  the  first  twenty-one  days  after  disability  begins  the  employer 
shall  be  liable  for  reasonable  medical  and  hospital  services  and  medicines 
as  and  when  needed,  not,  however,  to  exceed  $200  dollars  in  value,  unless 
the  employee  refuses  to  allow  them  to  be  furnished  by  the  employer;  Pro- 
vided, however,  that  where  the  injured  employee  refuses  or  neglects  to  avail 
himself  of  such  medical  or  surgical  treatment,  the  employer  shall  not  be  liable 
for  any  aggravation  of  such  injury  due  to  said  neglect  or  refusal. 

Texas: 

During  the  first  week  of  the  injury,  the  Association  shall  furnish  medical 
aid,  hospital  services  and  medicines  when  needed,  and  if  it  does  not  furnish 
them  immediately  as  and  when  needed,  it  shall  repay  all  sums  reasonably 
paid  or  incurred  for  same,  provided  notice  of  injury  shall  be  given  to  the  said 
Association,  and  this  provision  requiring  notice  shall  apply  to  all  subsequent 
sections  of  this  Act,  providing  for  compensation. 

Connecticut : 

The  employer  shall  provide  a  competent  physician  or  surgeon  to  attend 
any  injured  employee  during  the  30  days  immediately  following  the  injury, 
as  such  injury  may  require,  and  in  addition  shall  furnish  such  medical  and 
surgical  aid  or  hospital  service  during  such  3®  days  as  such  physician  or 
surgeon  shall  deem  reasonable  or  necessary.  In  the  event  of  the  failure 
of  the  employer  promptly  to  provide  such  physician  or  surgeon,  or  such 
medical  or  surgical  or  hospital  services  during  any  portion  of  such  30  days, 
the  injured  employee  may  provide  such  physician  or  surgeon  or  medical  or 
surgical  or  hospital  service  at  the  expense  of  the  employer,  or  at  his  option 
the  injured  employee  may  refuse  the  medical,  surgical  and  hospital  services 
provided  by  his  employer  and  provide  the  same  at  his  own  expense.  If  it 
so  appears  to  the  Commissioner,  that  an  injured  employee  has  refused  to 
accept  and  failed  to  provide  such  reasonable  medical,  surgical  or  hospital 
care,  all  rights  of  compensation  under  this  Act  shall  be  suspended  during 
such  refusal  or  failure.  The  pecuniary  liability  of  the  employer  for  the 
medical,  surgical  and  hospital  services  herein  required  shall  be  limited  to  such 
charges  as  provided  in  the  same  community  for  similar  treatment  of  injured 
persons  of  a  like  standard  of  living,  when  such  injury  is  paid  for  by  the  in- 
jured persons. 


162 

West  Virginia: 

The  Commission  shall  disburse  and  pay  from  the  fund  for  such  injury 
to  such  employees  as  may  be  entitled  thereto  hereunder,  such  amounts  for 
medical,  nurse  and  hospital  services  and  medicines  as  it  may  deem  proper, 
not,  however,  in  any  case  to  exceed  the  sum  of  $150.  In  addition  to  such 
award  to  such  employee,  payment  to  be  made  to  the  employee  or  to  the 
persons  who  may  have  furnished  the  service  and  supplies  or  to  the  persons 
who  may  have  advanced  payment  for  the  same,  as  to  the  Commission  shall 
seem  proper;  provided,  however,  that  in  case  any  injured  employee  be  entitled 
under  contract  connected  with  his  employment  or  elsewhere,  to  hospital  or 
medical  services  without  further  charge  to  him,  no  payment  shall  be  given 
out  of  the  Workmen's  Compensation  fund  for  hospital  or  medical  service. 

We  observe  from  these  sections  of  the  various  acts,  that  a 
wide  divergence  of  application  is  made,  condensing  in  several 
instances  not  only  the  amount  for  medical  and  surgical  services, 
but  also  for  hospital  treatment,  medicines,  medical  and  surgical 
supplies,  crutches,  apparatus  and  nursing,  and  in  none  of  them 
does  the  total  amount  exceed  the  sum  of  $250. 

We  also  observe  that  in  no  act  where  a  commission  has  charge 
or  where  the  payment  is  derived  from  an  insurance  company, 
has  the  patient  the  right  of  selection  as  to  his  medical  or  surgical 
attention  or  his  hospital. 

What  conclusion  may  we  draw  concerning  the  influence,  benefits 
and  possibilities  to  the  profession  of  the  states  in  the  application 
of  the  law  now  in  force,  and  what  may  we  construe  will  be  the 
future  of  medicine  under  the  application  of  the  workmen's  com- 
pensation acts? 

We  are  of  the  opinion  that  the  principles  laid  down  both  in 
Europe  and  in  states  now  having  these  laws,  are  of  great  advantage 
to  the  people  for  their  good,  and  when  properly  applied  are  right 
and  just. 

It  would  seem  to  us  that  errors  have  occurred  in  the  framing 
of  bills  passed  by  the  legislatures  of  many  states,  in  not  getting 
closer  to  the  medical  profession  of  the  states  as  to  their  opinion 
and  advice,  relative  to  that  section  of  the  acts  pertaining  to  the 
application  of  medical,  surgical  and  hospital  service. 

As  has  previously  been  stated,  when  injury  occurs  the  first 
party  called  is  the  surgeon,  and  upon  him  will  rest  the  greater 


responsibility  of  conserving  the  finances  of  the  corporation  or  the 
insurance  company,  who  are  to  pay  the  awards  when  the  time 
conies  for  final  settlement. 

One  of  the  obstacles,  no  doubt,  in  the  successful  application 
of  this  portion  of  the  act  is  political  appointment  of  local  ex- 
aminers, and  favoritism  that  must  in  most  states  apparently 
pollute  an  otherwise  good  and  beneficial  measure. 

We  believe  in  all  states  the  physician's  bills  should  be  paid 
direct  to  him  and  not  to  the  workman. 

Thorough  cooperation  upon  the  part  of  the  medical  profession 
of  the  state  would  of  necessity  be  required,  and  as  such  we  believe 
that  only  members  of  component  county  societies,  in  good  stand- 
ing, should  be  appointed  to  operate  the  medical  provisions  of 
this  act.  Hospitals  should  be  placed  upon  an  equal  basis.  The 
patient  should  have  the  privilege  of  employing  a  physician  of 
his  choice,  but  said  physician  should  be  of  sufficient  proficiency 
and  ability  to  do  good  work,  and  where  it  is  proven  that  they  are 
incompetent,  a  plan  should  be  made  to  have  such  incompetency 
apply  to  their  dismissal  from  competent  societies  or  units, 
and  that  the  public  should  be  made  aware  of  the  necessity  for 
the  employment  of  the  best  surgical  skill  they  can  obtain. 

There  must  of  necessity  be  a  uniformity  of  fee-bills,  and  where 
the  greatest  contention  has  been  made,  it  has  been  brought 
by  those  who  have  a  desire  to  frustrate  such  plan  for  uniformity. 

The  Ohio  Medical  Journal  of  December  last,  says : 

The  average  medical  award  has  floated  between  $7.50  and  $8.00  and  con- 
stitutes a  little  less  than  1/$  of  the  average  award,  which  has  been  between 
$25  and  $30.  In  10,000  cases  99  per  cent,  have  been  adjusted  without 
difficulty,  so  far  as  the  medical  aspect  goes.  This  certainly  is  a  record  which 
gives  the  Department  high  hopes  of  aqoiding  trouble.  The  Department 
says  we  have  put  the  medical  problem  into  the  hands  of  the  physicians  them- 
selves, retaining  always  the  power  to  control  and  relying  on  the  absolute 
justice  which  resides  in  the  heart  of  that  great  profession  to  render  excellent 
service  for  a  fair  reward,  and  thus  to  participate  in  the  glory  of  establishing 
Workmen's  Compensation  on  an  enduring  and  just  basis. 

To  this  comment  we  would  add  that  the  dollar  earned,  when 
paid  by  the  department  or  by  an  honest  insurance  company, 
is  a  dollar  paid  and  should  be  more  gratefully  received  than  in  the 


i64 

cases  where  long  waits,  intermittent  payments  and  lost  accounts 
give  the  balance  in  favor  of  so-called  charity. 

There  are  many  vicious  sides  to  the  compensation  acts  when 
not  properly  framed  or  properly  administered.  The  contract 
practice,  at  fees  much  less  than  those  of  profession  in  the  locality; 
hospitals  taking  patients  on  the  dollar  per  month  plan;  when 
workmen  pay  for  their  services,  to  clubs  or  medical  funds,  to  con- 
tract for  this  work  and  the  general  profession  be  left  out  of  con- 
sideration at  time  of  accident;  discord  in  the  practice  of  medicine 
in  localities  where  men  are  not  on  the  square,  as  to  their  pro- 
fessional work,  or  where  members  of  county  societies  or  units, 
do  not  respect  the  rules  of  their  organization. 

When  workmen  properly  appreciate  the  advantages  of  the 
assistance  rendered  by  workmen's  compensation  acts,  the 
medical  aid  rendered  without  cost  to  themselves,  relieving  them 
of  obligations  to  their  doctor,  it  should  make  it  possible  for  them 
to  pay  more  promptly  for  other  services  rendered  to  themselves 
and  families. 

Consideration  must  be  given  to  the  subject  of  prosecution  for 
alleged  malpractice,  in  cases  coming  under  the  compensation 
acts,  as  statistics  in  various  states,  having  defense  funds,  show 
an  increase  in  this  form  of  prosecution. 

NOTE. — The  author  wishes  to  give  credit  for  free  extracts  from 
compilation  of  workmen's  compensation  acts,  prepared  under 
the  direction  of  Royal  Meeker,  Commissioner  of  Labor  Statistics. 


165 


APPENDIX. 
EXTRACTS  FROM  TABLE  OF  "PRINCIPAL  FEATURES  OF  LAWS  RELATING  TO 

WORKMEN'S  COMPENSATION  AND  INSURANCE." 

PREPARED  UNDER  THE  DIRECTION  OF  ROYAL  MEEKER,  COMMISSIONER  OF  LABOR 

STATISTICS. 


Twenty-three  States. 


SYSTEM  PROVIDED  FOR. 

States. 

12  Compensation  elective. 

3  Compulsory  compensation. 

3  Insurance  elective. 

4  State  insurance  elective. 

i     State  insurance  compulsory. 


INDUSTRIES  COVERED. 


States. 
2 
3 


All. 

All  (except  casual  employees 
and  those  not  exposed  to 
hazards  of  employments). 

All  (except  domestic  and  agri- 
cultural labor). 

Especially  dangerous  (enumer- 
ated list)  where  5  or  more 
workmen  are  employed. 

Especially  dangerous  (enumer- 
ated list)  elective  as  to  all 
others. 

All  except  railroads,  etc.,  in  in- 
terstate commerce  and  do- 
mestic and  agricultural  labor, 
casual  employees  excepted. 

All  employing  more  than  5 
workmen. 

All  but  railroads. 

Hazardous  employments  (ex- 
tensive list),  domestic  and 
agricultural  labor  excluded. 

All  employing  2  or  more  work- 
men. 

Hazardous  (enumerated  list), 
others  if  employers  elect. 

Extra  hazardous  (enumerated 
list),  elective  as  to  all  others. 

Dangerous  (enumerated  list). 

All  employing  more  than  two 
workmen. 


1 66 


How  ELECTION  is  MADE. 


To  ACCEPT  OR  REJECT. 


BY  EMPLOYER. 

States. 

2     Presumed  in  absence  of  notice. 

1  Presumed  as  to  employers  in 

hazardous  employment  in 
absence  of  written  notice; 
other  employees  file  notice. 

2  In  absence  of  notice  posted  in 

establishments  and  filed  with 
Industrial  Commissioner. 

i  Presumed  in  absence  of  notice 
posted  in  establishment  and 
filed  with  Secretary  of  State. 

i  Writing  filed  with  Accident 
Board. 

i  Presumed  in  absence  of  notice 
posted  in  establishment  and 
filed  with  Commissioner  of 
Labor. 

i  Presumed  in  absence  of  notice 
posted  in  establishment  and 
filed  with  Insurance  Com- 
missioner. 

i  Writing  filed  with  Commis- 
sioner of  Labor. 

i  Presumed  in  absence  of  written 
notice  to  employees. 

i  Writing  filed  with  County 
Clerk. 

i  Writing  filed  with  Commis- 
sioner of  Industrial  Statistics. 

i  Presumed  as  to  employers  of  4 
or  more  persons  (except  rail- 
roads); no  absence  of  notice 
filed  with  Industrial  Commis- 
sion; other  employees  may 
elect  by  filing  notice. 
By  contract  in  writing  with  em- 
ployee. 


BY  EMPLOYEE. 


State 


i  Presumed  in  absence  of  writ- 
ten notice. 

4  Presumed  in  absence  of  written 
notice,  if  employer  elects. 

i  Presumed  in  absence  of  written 
notice  to  employer  and  Indus- 
trial Commission. 

i  Presumed  in  absence  of  writ- 
ten notice  filed  with  Secre- 
tary of  State. 

i  Presumed  in  absence  of  notice 
to  employer  and  filed  with 
Commissioner  of  Labor. 

i  Presumed  in  absence  of  notice 
to  employer  and  filed  with 
Insurance  Commission. 

1  By  accepting  compensation  or 

beginning  proceedings  under 
the  act. 

2  Presumed  in  absence  of  written 

notice  to  employer. 

i  Writing  filed  with  County 
Clerk. 

i  Presumed  in  absence  of  writ- 
ten notice  to  employer  if  em- 
ployer elects,  on  railroad, 
where  acceptance  must  be  in 
writing. 

i  By  contract  in  writing  with 
employer. 

i  Presumed  in  absence  of  written 
notice,  if  employers  in- 
sure. 

i  Presumed  in  absence  of  notice 
to  employer  and  filed  with 
Commission. 

i     No  option. 


167 
BY  EMPLOYER.  BY  EMPix>YE3. 

States.  States. 

2     By  subscribing  to  State  Asso-          i     Remaining  in  service,  with  no- 
ciation,  or  insuring  in  other  tice  of  employer's  election. 

Company.  4     No  provision. 

i  Presumed  as  to  employment  in 
hazardous  employments  in 
absence  of  waiver  posted  in 
establishment,  and  filed  with 
Commissioner ;  other  em- 
ployers file  acceptance. 

i  By  payment  of  premiums  and 
posting  notice. 

4     No  provision. 

DEFENSE  ABROGATED  IF  EMPLOYER  DOES  NOT  ELECT. 

States. 

i         Assumed  risk,  fellow  service  and  contributory  negligence,  except  as 
to  casual  employers  of  not  less  than  5  persons. 

1  Assumed  risk,  fellow  service  and  contributory  negligence  as  to  em- 

ployer in  designated  hazardous  employments. 

6         Assumed   risk   and   fellow   service;   contributory   negligence,    unless 
wilful. 

2  Assumed  risk  and  fellow  service;  contributory  negligence  to  be  mea- 

sured. 

2         Assumed  risk,  fellow  service  and  contributory  negligence,  except  in 
suits  by  domestic  and  farm  laborers. 

i         None  (assumed  risk,  fellow  service  and  contributory  negligence  re- 
stricted by  liability  provisions  of  statute). 

i         None;  restricted  defense  of  assumed  risks  and  fellow  service;  re- 
quires proof  of  contributory  negligence. 

i         Assumed  risk,  fellow  service  and  contributory  negligence,  except  for 
domestic  and  farm  labor  and  employers  of  5  or  less  persons. 

i         Assumed  risks;  also  fellow  service  and  contributory  negligence,  un- 
less wilful,  if  4  or  more  employees. 

i         Assumed  risk,  fellow  service  and  contributory  negligence,  and  negli- 
gence of  statutory  employee. 

6         No  provision. 

SUITS  FOR  DAMAGE  ARE — 

6         Not  permitted  after  electing  compensation. 

1  Not  permitted  after  electing  compensation,   unless  employer  is  in 

default  on  insurance  premiums, 

2  Permitted  in  lieu  of  compensation. 

4         Permitted  after  elective  to  receive  compensation. 


168 

States. 

i         Permitted  in  lieu  of  compensation  if  employer  was  guilty  of  serious 

or  wilful  misconduct  or  violated  safety  law. 

i         Permitted  in  lieu  of  compensation  if  employer  was  grossly  negligent 
i         Permitted   if  employer  fails   to   secure   payment   of   compensation; 
defense  of  fellow  service,  assumed  risks  and  contributory  negli- 
gence abrogated. 

1  Permitted  if  injury  is  due  to  the  failure  of  the  employer  to  comply 

with  safety  laws. 

2  Not  permitted  after  employer's  election,  unless  he  is  in  default  on 

premiums, 
i         Permitted  if  injury  was  due  to  employer's  failure  to  comply  with 

safety  laws,  or  his  intention  to  injure,  or  employer  is  in  default  on 

insurance  premiums, 
i         Not  permitted  against  employers  accepting  insurance  system,  except 

for  wilful  or  gross  negligence,  causing  death, 
i         Permitted  if  injury  was  due  to  wilful  act  of  employer;  his  failure  to 

comply  with  safety  law;  or  if  he  is  in  default  on  premiums. 

1  Permitted  in  addition  to  insurance  premiums,  if  injury  resulted  from 

deliberate  intention  of  employer. 

SPECIAL  CONTRACTS. 

2  Approved  schemes  may  be  substituted. 

5  Employers  may  insure  or  maintain  in  a  benefit  fund,  but  may  not 
refuse  liability  fixed  by  law. 

i  Approved  scheme  may  be  substituted,  but  no  reduction  of  liability 
allowed. 

5         Forbidden. 

i         No  substitute  agreement  valid. 

i         Permitted  if  compensation  is  provided  not  less  than  that  of  the  act. 

i  Law  is  based  on  contracts  with  casualty  companies.  Employer  of 
not  less  than  1,000  persons  may  maintain  establishment  funds. 

i         Employer  must  insure  in  authorized  company  or  state  association. 

I  No  waiver  permitted;  insurance  with  other  companies  must  conform 
to  law. 

i         Not  permitted. 

i  Approved  schemes  or  insurance  permitted;  must  contribute  to  sur- 
plus fund  of  United  States. 

3  No  provision. 

BURDEN  OF  COST  ON. 
20        Employer, 
i         Employer,  not  less  than  50  per  cent,  (plus  cost  of  management  in 

case  of  establishment  funds),  remainder  on  employees, 
i         Employees  one-half  of  i  per  cent,  (not  less  than  25  cents  per  month) ; 

employer  6  times  as  much;  state  subsidiary, 
i         Employer  90  per  cent. ;  employee  10  per  cent. 


169 
SECURITY  OF  PAYMENTS. 

States. 

3         Employer  must  give  proof  of  solvency  or  insurance  risks. 

i  Employer  must  give  proof  of  financial  ability;  furnish  security;  insure 
or  make  other  provision  for  security. 

i  Bond  may  be  required  to  secure  lump  sums  awarded  by  court;  in- 
surers have  rights  and  duties  of  insured  employees. 

i  Employer  must  give  proof  of  financial  ability  or  procure  state  mutual 
or  private  insurance. 

i         If  insolvent,  claims  are  a  first  lien. 

i  If  insured  employer  is  insolvent;  claims  are  enforcible  directly  against 
the  company. 

1  Employer  must  give  proof  of  financial  ability  or  give  bond. 

2  Compensation  payments  are  preferred  claims  on  assets  of  employer, 
i         Payments  are  a  claim  superior  to  incurred  debts. 

i         Judgments  awarding  compensation  have  same  preference  as  wage 

debts. 

i         Payments  have  same  preference  as  wage  debts, 
i         Employer  must  give  proof  of  financial  ability  (deposit  of  securities 

may  be  required)  or  procure  state  mutual  or  private  insurance, 
i         Establishment  funds  must  be  held  as  trust  funds, 
i         State  control  of  employee's  insurance  association. 
6         Insurance  has  no  state  control. 

To  BE  COMPENSATED  DISABILITY  MUST  CONTINUE. 
1 1         More  than  2  weeks, 
i         More  than  6  days;  then  compensation  from  8th  day. 

3  More  than  2  weeks  (payment  from  date  of  injury,  if  disability  lasts 

8  weeks  or  more). 
i         More  than  i  week  (payment  for  first  week  if  disability  lasts  more 

than  4  weeks). 

i         At  least  2  weeks,  then  compensation  from  date  of  accident, 
i         Any  time. 
3         More  than  i  week. 

i         Loss  of  earning  power  shall  exceed  5  per  cent, 
i         At  least  i  week  if  so  provided  in  the  contract. 

COMPENSATION  FOR 


Medical  and 

Death. 

Total  disability. 

Partial  disability. 

surgical  aid. 

$100       funeral       ex- 

50 per  cent,  of  earn- 

50 per  cent,  of  wage 

During  first  30  days. 

penses  ;  50  per  cent. 

ings  for  not  over 

decrease;  $10  max. 

of   wages   for   312 

520    weeks;    $5 

for   not   over   312 

weeks;     $5     min., 

min.,  $10  max. 

weeks;    fixed  rates 

$10   max.;   no  de- 

for    specified     in- 

pendents, $750  to 

juries. 

state        expense 

fund. 

170 


COMPENSATION  FOR 


Medical  and 

Death. 

Total  disability. 

Partial  disability. 

surgical  aid. 

4     years'     earnings; 

50  per  cent,  of  week- 

50 per  cent,  of  wage 

During    first    8    weeks 

$1,500             min., 

ly   earnings   for   8 

decrease;  $12  max. 

not  over  $200;  physi- 

$3,500   max.;    no 

years;  $5  min.,  $12 

for  not  more  than 

cian  or  surgeon  dur- 

dependents, $150. 

max.,  up  to  $3,  500. 

8  years;  fixed  rates 

ing  disability,  unless 

for  specified  inju- 

employee prefers  his 

ries. 

own. 

Funeral       expenses, 

50  per  cent,  of  wages 

Fixed  rates  for  speci- 

During   first    2    weeks. 

not  over  $100;  50 

for  400  weeks;  $5 

fied   injuries;   pro- 

not   over    $100,    in- 

per cent,  of  wages 

min.,   $10   max. 

portionate           for 

cluding      burial      if 

for  300  weeks;  $5 

others;    $5     min., 

injury  was  fatal. 

min.,   $10   max. 

$10  max. 

3     years'     earnings; 

50  per  cent,  of  week- 

25 to  50  per  cent,  of 

Only  if  employee  dies, 

$1,200             min., 

ly     earnings  ;      $3 

weekly     earnings; 

leaving    no    depend- 

$3,600   max.;    no 

min.,     $15     max., 

$3  min.,  $12  max. 

ents. 

dependents,  $100. 

for  not  more  than 

for  not  more  than 

8  years. 

8  years. 

50  per  cent,  of  wages 

50  per  cent,  of  wages 

50  per  cent,  of  wage 

During       first       three 

for      300      weeks; 

for   not   over   500 

decrease;  $10  max. 

weeks. 

$4  min.,  $10  max.; 

weeks;     $4     min., 

for   not   over   300 

no         dependents, 

$10     max.;     total 

weeks;  fixed  rates 

$200. 

not       to       exceed 

for     specified     in- 

$4,000. 

juries. 

25  to  60  per  cent,  of 

50  per  cent,  of  wages 

50  per  cent,  of  wage 

During   first    90    days, 

wages      for      300 

for  400  weeks;  $6 

decrease    for    300 

not  over  $100,  or  by 

weeks;     $6     min., 

min.,  $10  max. 

weeks;     $6     min., 

order  of  court,  $200. 

$10  max.;  no  de- 

$10    max.;     fixed 

pendents,  $100. 

rates  for  specified 

injuries. 

$100      funeral      ex- 

50 per  cent,  of  wages 

50  per  cent,  of  wage 

During   first    3    weeks. 

penses;  50  per  cent. 

for  300  weeks;  $5 

decrease;           $10 

not  to  exceed  $20. 

of   wages  for   350 

min.,     $10     max., 

max.,       for       300 

weeks;     $5     min.. 

then  40  per  cent. 

weeks;  fixed  rates 

$10  max. 

of     wages     during 

for     specified     in- 

life;   $4    min.,    $8 

juries. 

max. 

1  50     times     weekly 

50  per  cent,  of  aver- 

50 per  cent,  of  wage 

Only  if  employee  dies. 

earnings,  not  more 

age    weekly   earn- 

loss; $10  per  week 

leaving    no    depend- 

than    $3,000;     no 

ings;       $10     max. 

for  not  more  than 

ents. 

dependents,   $100. 

for  not  more  than 

300  weeks. 

300  weeks. 

35  to  60  per  cent,  of 

50      per     cent.      of 

Fixed  scale  for  speci- 

During first    2    weeks. 

wages       for      300 

wages      for      400 

fied  injuries;  oth- 

not over  $50. 

weeks;     $5     min., 

weeks;     $5     min., 

ers  proportionate. 

$10    max.;  no  de- 

$10 max. 

pendents,  $100. 

1,200     times     daily 

50  per  cent,  of  wages 

50  per  cent,  of  wage 

Only  if  employee  dies 

earnings;      $3,000 

(not     more     than 

decrease  ;        same 

leaving    no    depend- 

max.; no  depend- 

$10    weekly)     for 

limits  as  for  total 

ents. 

ents,    $100. 

not   more   than    8 

disability. 

years. 

COMPENSATION  FOR 


Medical  and 

Death. 

Total  disability. 

Partial  disability. 

surgical  aid. 

50  per  cent,  of  week- 

50 per  cent,  of  week- 

50 per  cent,  of  wage 

Reasonable  services  for 

ly   wages   for   300 

ly  earnings  for  not 

decrease,  $10  max. 

first  2   weeks;  $200 

weeks;     $4     min., 

over    500     weeks; 

for  not  more  than 

max.   in  fatal    cases 

$10  max.;  no  de- 

$4 min.,  $10  max. 

300    weeks;    fixed 

with      no      depend- 

pendents, $200. 

rates  for  specified 

ents;      including 

injuries. 

burial. 

4  years'  earnings,  but 

65  per  cent,  of  wages; 

65  per  cent,  of  wage 

For  not  more  than  90 

amount   added   to 

if  nurse  is  required 

decrease;  no  total 

days. 

prior         disability 

100  per  cent,  after 

to  exceed  4  years' 

payments  may  not 

90  days;  no  total 

earnings;         fixed 

exceed     6     years' 

to  exceed  6  years' 

rates  for  specified 

earnings;     no    de- 

earnings. 

injuries  . 

pendents,   $100. 

2,400  times  one-half 

50  per  cent,  of  aver- 

50 per  cent,  of  wage 

Only  if  employee  dies, 

the    daily    wages; 

age   semi-monthly 

decrease  until  re- 

leaving   no    depend- 

$4,000    max.;     no 

earnings,      during 

covery,  not  to  ex- 

ents. 

dependents,    med- 

disability,   not   to 

ceed  $4,000. 

ical  and  burial  ex- 

exceed  $4,000. 

penses. 

3      years'     earnings; 

65  per  cent,  of  wages 

65  per  cent,  of  wage 

During  first  90  days. 

$1,000  min.,  $5,000 

for      240      weeks, 

decrease  for  fixed 

max.;   no  depend- 

then 40  per  cent. 

periods,       propor- 

ents, $100. 

for  life. 

tionate     to     disa- 

bility. 

$100  funeral    expen- 

662/3 per  cent,   dur- 

662/»   per    cent,     of 

During   first   60   days. 

ses;  widow  or  wid- 

ing     continuance; 

wage         decrease, 

ower,  30  per  cent. 

$5  min.,  $15  max. 

fixed      scale      for 

of      wages      until 

specified    injuries; 

death    or    re-mar- 

$5 min.,  $15  max.; 

riage;  10  per  cent. 

for  certain  maim- 

additional  for  each 

ings,  $20  max. 

child      under      18 

years;     not     over 

662/s      per      cent. 

total. 

3     years'     earnings; 

50  per  cent,  average 

Difference     between 

Only  if  employee  dies. 

$1,000     min.;     no 

weekly  wages  dur- 

amount   for    total 

leaving    no    depend- 

dependents,      $75 

ing     previous     12 

disability  and  amt. 

ents. 

min.,  $100  max. 

months,  if  so  long 

workman      is      to 

in  employer's  ser- 

earn after  the  in- 

vice; if  not,  then  a 

jury;     fixed     pro- 

weekly benefit  for 

portion  for  special 

such    shorter    pe- 

injuries. 

riod  as  he  may  have 

been  in  such  ser- 

vice. 

50  per  cent,  of  wages 

50  per  cent,  of  wages 

50    per    cent,    wage 

During  first  2  weeks. 

for  400  weeks;  $4 

for   not   over   500 

loss,  $10  max.  for 

min.,  $10  max.;  no 

weeks;     $4     min., 

not  more  than  300 

dependents,  $200. 

$10  max.;  total  not 

weeks;  fixed  rates 

to  exceed  $3,000. 

for  speciaHn  juries. 

172 


COMPENSATION  FOR 


Death. 

Total  disability. 

Partial  disability. 

$125  burial  expenses 

50  per  cent,  earnings 

50  per  cent,  wage  de- 

and  50   per  cent. 

for     100    months; 

crease,    $40    max. 

earnings    for    100 

$20  min.,  $60  max.; 

for  not  more  than 

months;  $20  min., 

total  not  to  exceed 

60    months;    fixed 

$60     max.;     total 

$5,000. 

rates    for    special 

not       to       exceed 

injuries. 

$5,000.       No     de- 

pendents,      $125, 

medical  and  burial 

expenses. 

$100       burial        ex- 

$30   per    month,    if 

Proportionate   bene- 

penses;  widow   or 

single,   $35   if  de- 

fits  for  not   more 

invalid     widower, 

pendent       spouse; 

than    2    years,    if 

$30  per  month  un- 

$6   additional    for 

temporary;      fixed 

til  death  or  re-  mar- 

each   child;    total 

rates  for  special  in- 

riage ;  $6  additional 

not  to  exceed  $50. 

juries. 

for  each  child  un- 

der   16;   total  not 

to    exceed    $50. 

Medical  and 
surgical  aid. 

Only  if  employee  dies, 
leaving  no  depend- 
ents. 


Not  to  exceed  $250. 


60  per  cent,  of  wages  60   per   cent,    wages  60  per  cent,  wage  de-     During  first  week, 

for  360  weeks;  $5  for   not   over   400          crease;    $15    max. 

min.,  $15  max.;  no  weeks;     $5     min.,         for   not   over   300 

beneficiaries        or  $15  max.                           weeks;  fixed  rates 
creditors,  $100.                                                         for  special  injuries. 


$75  burial  expenses;     50   per   cent,    wages     50  per  cent,  wage  de-     Not  to  exceed  $150. 
widow   or   invalid         until     death;     $3         crease;     $4     min., 
min.,   $6   max.  $8    max.     for     26 

weeks;  loss  of 
arm,  leg  or  eye, 
156  weeks. 


widower,  $20 
until  death  or  re- 
marriage; $5  ad- 
ditional for  each 


child     under  14; 

total     not    to  ex- 
ceed $35. 

,$150      funeral  ex-     662/J  per  cent,  wages     662/»    per    cent,     of     Not  to  exceed  $200. 


penses;  662/s  per 
<cent.  wages  for  6 
years;  $1,500  min., 
$3,750  max. 


$75  funeral  expenses; 
widow  or  invalid 
widower  receives 
$20  monthly  until 
death  or  re-mar- 
riage ;  each  child 
under  16,  $5  per 
month;  total  not 
to  exceed  $35. 


until  death,  if  per- 
manently disabled ; 
$5  min.,  $12  max. 


$20  per  month  if  sin- 
gle, $25  if  married; 
for  each  child  un- 
der 16  years,  $5 
per  month;  not 
over  $35  in  all. 


wage  decrease,  $  1 2 
per  week  max. ; 
not  over  $3,750  in 
all;  fixed  rates  for 
special  injuries. 


Proportionate; 
over  $1.500. 


not 


50  per  cent,  of  benefits 
added  for  first  6 
months  of  total  dis- 
ability; not  more 
than  60  per  cent,  of 
wages  in  all. 


173 
TIME  FOR  NOTICE  AND  CLAIM. 

States. 

i         Notice  in  30  days,  claim  in  i  year. 

i  Notice  as  soon  as  practicable,  not  later  than  30  days,  claim  in  6 
months. 

i  Notice  in  15  days;  if  in  30  days  not  barred,  except  as  to  extent  em- 
ployer was  prejudiced;  bar  absolute  after  90  days. 

i         Same,  except  14  days,  claim  in  i  year. 

i         Same,  except  14  days. 

i         Notice  in  10  days,  claim  in  6  months. 

i         Notice  in  3  months,  claim  in  6  months. 

1  Notice  as  soon  as  practicable;  claim  in  6  months;  petitions  filed  in 

any  court  in  one  year. 

2  Notice  as  soon  as  practicable  and  before  leaving  service;  claim  in  6 

months. 

i         Notice  in  30  days,  claim  in  one  year, 
i         Notice  in  30  days,  claim  in  two  years, 
i         Notice  in  two  weeks ;  none  required  in  case  of  death  or  compensation 

action  on  claim  within  one  year. 

i         Notice  in  30  days,  claim  in  6  months  for  disability,  i  year  for  death, 
i         Notice  of  injury  in  10  days,  of  death  in  30  days,  unless  excused  for 

cause;  claim  in  one  year. 

1  Contract  may  require  reasonable  and  timely  notice. 

2  Notice  as  soon  as  practicable;  claim  in  6  months. 

1  Applications  must  be  made  and  claims  enforced  in  one  year. 

2  Claim  in  one  year. 

i         Claim  in  6  months, 
i         To  be  fixed  by  board. 

DISPUTES  SETTLED  BY 

i  Compensation  commissioners;  appeals  to  courts. 

i  Arbitration  for  each  case,  subject  to  review  by  industrial  board  and 
appeals  to  court. 

i  Industrial  commissioner  and  two  others  as  arbitrators;  limited  ap- 
peal to  court. 

i  Local  committee  or  arbitrators;  court  review  allowed. 

i  Industrial  accident  board  arbitration;  appeals  to  supreme  court. 

i  Courts. 

i  Arbitrators  or  district  court  of  county. 

i  Proceedings  in  equity. 

i  Judges  of  common  pleas;  limited  appeal  to  supreme  court. 

i  Arbitration  of  courts. 

i  Courts  in  summary  proceedings. 

i  Industrial  commission;  appeal  to  courts. 


174 

States. 

i  Arbitration;  reference  to  attorney  general;  appeal  to  courts. 

4  Industrial  accident  commission;  limited  appeals  to  courts. 

i  Workmen's  compensation  commission;  limited  appeals  to  courts. 

i  Arbitration,  if  so  provided  in  contract. 

i  Arbitrators  for  each  case;  industrial  accident  board;  appeals  to  courts 

on  points  of  law. 

i  Industrial  commission. 

i  Public  service  commission;  limited  appeals  to  court, 

i  Industrial  insurance  department;  appeals  to  court. 


XXII. 

DISCUSSION. 

Dr.  Thomas  Wray  Grayson,  Pittsburgh: 

In  listening  to  the  papers  read  today  I  have  been  struck  with  something 
that  has  occurred  to  me  in  other  meetings  of  the  Academy  of  Medicine — the 
many  ways  in  which  different  speakers  can  look  at  a  subject.  Points  have 
been  brought  out  that  I  had  never  thought  of  in  looking  over  the  program. 

Dr.  Price  refers  to  the  inspection  of  our  manufacturing  establishments  as 
being  inadequate.  My  acquaintance  with  that  subject  is  not  extensiv,  but 
I  can  say  that  in  Pennsylvania,  altho  we  have  very  good  laws  governing  fac- 
tory inspection,  such  inspection  is  very  inadequate.  I  know  a  number  of 
instances  in  which  injuries  were  received  and  the  safeguards  were  afterward 
put  in  by  the  employers  without  requirement  by  the  factory  inspector. 

Dr.  Tuckerman  speaks  of  industrial  insurance  and  of  the  advantage  of  having 
the  Academy  take  up  this  subject.  I  know  of  no  body  in  this  country  that 
could  handle  the  matter  better  than  this  Academy. 

Dr.  Estes  has  spoken  of  the  8-,  10-  or  1 2-hour  day  in  the  mills.  In  Pitts- 
burgh, the  8-  or  lo-hour  day  is  quite  a  live  subject.  It  is  true  that  in  the  8- 
hour  day  much  more  has  been  accomplisht  than  in  the  12.  One  of  the  reasons 
assigned  for  this  is  better  organization  of  the  work  and  improvement  of  ma- 
chinery. That  brings  us  to  a  very  vital  problem,  the  question  of  speeding 
up  and  the  bonus  system.  Those  of  you  who  have  read  the  Pittsburgh 
Survey  will  remember  that  Mr.  Fitch  has  a  chapter  in  which  he  speaks  of  this 
system  in  a  derogatory  way.  He  believes  it  one  of  the  worst  features  in  the 
steel  industry.  This  is  not  the  case  except  in  a  limited  way.  He  gives  one 
side  of  the  question.  From  the  employer's  standpoint  it  looks  entirely  differ- 
ent. There  is  a  minimum  amount  of  work  required  which  can  easily  be  done. 
Beyond  this  amount  the  men  are  given  a  bonus.  Of  course  this  system  is 
applied  to  many  industries.  For  instance  the  system  works  out  in  the  West- 
inghouse  plant  and  I  cannot  see  the  evils  of  it. 

You  would  naturally  expect  one  from  Pittsburgh  to  speak  more  particularly 
of  the  things  for  which  Pennsylvania  is  noted — coal  mining,  railroading,  iron 
and  steel  and  smoke. 

Regarding  the  railroads:  Allegheny  County  is  one  of  the  largest  railroad 
centers  in  the  country  and  railroads  touch  on  our  subject  in  two  ways:  (i) 
Accident,  and  (2)  the  production  of  smoke.  These  will  be  mentioned  later. 

Coal  mining:  We  have  here  the  accidents  incident  to  coal  mining.  Con- 
sidering these  in  connection  with  the  large  foreign  population  in  the  coal  mines, 
I  cannot  forbear  saying  that  when  the  head  of  a  family  is  killed  in  the  coal 
mine,  it  seems  a  poor  compensation  for  his  family  to  be  given  a  few  hundred 
dollars  and  allowed  to  take  care  of  itself  or  sent  back  to  Europe.  It  is  consid- 
ered a  fine  thing  when  the  coal  company  pays  a  paltry  few  hundred  dollars. 


1 76 

Regarding  the  gas  in  coal  mines,  there  is  a  prevalent  idea  that  it  is  a  remedy 
for  whooping  cough.  One  mine  owner  I  heard  of  placed  two  of  his  children 
on  a  car  which  he  sent  into  a  coal  mine  for  this  purpose  and  it  is  said  that  the 
children  had  no  more  whooping  cough. 

In  the  iron  industry  much  of  the  ore  now  used  comes  from  the  Lake  Superior 
district  and  looks  like  a  heavy  brown  powder.  When  that  is  handled  and  put 
into  furnaces  immense  clouds  of  the  dust  are  scattered  over  the  neighborhood. 
This  ore  dust  is  a  great  menace  to  the  whole  community,  particularly  that 
part  around  the  mills.  It  kills  vegetation,  causes  windows  to  be  kept  closed 
and  is  breathed  in  much  as  smoke.  In  the  steel  mills  also  we  have  steel  dust 
floating  around,  irritating  the  eyes  and  the  respiratory  tract. 

Did  you  ever  think  of  the  noise  of  the  steel  mill,  the  terrible  roar  of  ma- 
chinery, the  hissing  of  steam,  the  clanging  of  the  doors  and  the  shouts  of  the 
men?  These  things  are  very  hard  on  the  workmen,  causing  deafness  and 
nerve  strain.  The  heat  in  summer  is  intolerable.  The  men  wear  as  little 
clothing  as  possible,  but  perspire  profusely  and  drink  enormous  quantities  of 
water.  A  common  acute  illness  in  the  mills  is  cramps  said  to  be  due  to  the 
excessiv  loss  of  fluid  from  the  body  by  perspiration.  In  the  winter  time,  too, 
these  men  perspire  freely.  Facilities  are  not  provided  for  change  of  their 
clothing.  A  man,  in  a  dripping  perspiration,  goes  out  into  a  temperature 
below  zero  and  it  is  no  wonder  that  pneumonias  are  so  prevalent  among  steel 
workers.  Sir  Thomas  Oliver  of  Great  Britain  gives  the  percentage  of  deaths 
from  pneumonia  as  37  among  steel  workers  which  is  far  above  the  average. 

A  steel  mill  is  never  idle.  The  men  are  changed  in  day  and  night  shifts 
and  this  is  particularly  hard  on  the  nervous  systems  of  the  men.  Imagine 
a  man  who  has  been  changed  to  the  night  shift,  trying  to  rest  during  the  day 
in  a  frame  house  in  a  noisy  neighborhood  with  the  August  sun  beating  on  the 
house.  Sleep,  if  possible,  would  not  be  very  refreshing.  It  is  no  wonder 
men  say  they  do  with  less  sleep  when  working  at  night  than  by  day. 

The  smoke  is  a  by-product — a  curse  of  which  we  are  just  beginning  to  realize 
the  awfulness.  There  was  a  time  when  we  were  positively  happy  in  this  con- 
dition in  Pittsburgh,  feeling  that  it  showed  our  prosperity,  but  that  time  is 
past.  We  were  then  "corrupt  and  contented"  as  Lincoln  Steffens  said.  Now 
we  are  awaking  to  the  knowledge  of  the  condition  and  taking  some  radical 
steps  to  lessen  the  trouble.  The  smoke  causes  damage  by  reason  of  the  parti- 
cles of  carbon  or  soot  floating  in  the  atmosphere.  One  of  our  department 
stores  in  Pittsburgh  has  estimated  that  the  dirt  causes  a  loss  of  $50,000  in  one 
year  by  damage  to  the  goods.  Vegetation  requires  more  care  in  Pittsburgh. 
There  is  a  similarly  bad  effect  upon  the  human  being.  Did  you  ever  think 
how  much  it  means  to  have  the  smoke  obscure  the  day-light?  Dr.  Jackson 
spoke  of  the  drawbacks  of  artificial  lighting.  When  the  atmosphere  is  laden 
with  smoke  it  means  that  the  natural  sunlight  is  dim  and  on  a  dark  day  in 
the  city  we  must  have  artificial  light  everywhere.  So  on  many  hours  of  the 
day  or  often  all  day  long  we  have  artificial  light  in  the  mills  and  offices.  No 


177 

lighting  engineer  has  found  a  way  of  making  artificial  light  as  satisfactory  to 
the  eyes  as  pure  sunlight.  When  the  air  is  laden  with  smoke  the  windows 
of  our  homes  are  kept  closed  and  ventilation  is  interfered  with.  The  smoke 
problem  is  one  of  greatest  importance. 

Dr.  Helen  C.  Putnam,  Providence: 

In  the  paper  on  "Home  Surroundings"  the  new  equipment  for  instruction 
in  "Domestic  Science"  in  elementary  schools  at  Pittsburgh  was  criticised 
as  too  unlike  what  pupils  have  to  work  with  in  their  homes.  In  numerous 
cities  in  other  countries  and  in  some  of  our  own,  school  boards  secure  a  regular 
cottage  or  flat,  or  small  city  house.  Here  the  pupils  keep  house  with  instruc- 
tors to  show  them  how.  Some  even  have  nurseries,  the  babies  being  brought 
in  for  a  few  hours  care  by  neighbors,  as  in  a  day  nursery.  Others,  more  wise, 
use  manikins  or  large  dolls. 

A  few  recent  reports  of  medical  studies  of  children  between  the  first  year 
of  infancy  and  school  age  are  showing  the  imperativ  need  of  regular  medical 
inspection  of  all  children  at  these  years,  to  check  ailments  in  their  incipiency 
and  to  lessen  very  greatly,  or  at  least  modify  medical  inspection  of  schools. 

Dr.  Forsyth,  in  the  Medical  Inspection  Center  of  the  City  of  Westminster 
in  London,  examined  374  "well  children,"  including  131  babies,  i.  e.,  under 
one  year.  Among  those  one  year  old  2.6  per  cent  had  defectiv  teeth;  among 
those  two  years  old,  seven  times  as  many  (18.1);  among  three  year  olds,  thir- 
teen times  as  many  (34);  among  four  year  olds,  twenty-four  times  as  many 
(63.6).  In  our  elementary  schools  we  are  finding  fifty  to  ninety  percent, 
have  carious  teeth  as  reported  by  various  inspectors.  The  older  the  children, 
the  more  extended  the  associated  systemic  or  local  damage. 

Tonsils  were  found  normal  in  these  babies;  but  in  the  second  year  over 
seven  in  a  hundred  were  found  enlarged  (7.8);  in  the  third  year,  twice  as 
many  (16.9);  in  the  fourth  year,  three  times  as  many  (24);  in  the  fifth  year, 
26.9  per  cent.  In  our  elementary  schools  from  thirty  to  forty  per  cent,  are 
reported. 

Adenoids  were  found  in  1.5  per  cent,  of  the  babies;  in  seven  times  as  many 
children  in  their  second  year  (10.4);  in  fifteen  times  as  many  in  their  third 
year  (22.9);  in  twenty-five  times  as  many  in  their  fourth  year  (38);  in  the 
fifth  year  in  33.3  per  cent.  In  our  elementary  schools  there  are  more  adenoids 
reported  than  enlarged  tonsils. 

Dr.  Forsyth  also  reports  on  other  details,  such  as  rickets,  etc.  These 
were  not  exceptionally  poor  or  misused  children  in  any  way,  and  the  lessons 
from  the  report  are  as  definit  for  us  as  for  England.  We  should  gradually 
enlarge  the  scope  of  our  "Mothers'  Consultations"  or  "Baby  Clinics"  to  in- 
clude, all  children  under  school  age.  These  conferences,  as  you  know,  are 
for  "well"  children,  to  instruct  mothers  in  keeping  them  well;  when  any  ail- 
ment is  found  the  children  are  sent  elsewhere  for  treatment.  The  growth  of 
vocational  schools  and  classes  in  homemaking  for  girls  over  15  years,  including 
even  married  women,  will  secure  better  care  of  young  children. 


I78 

Dr.  Henry  O.  Marcy,  Boston: 

I  should  like  to  ask  Dr.  Grayson  whether  they  have  had  any  success  in  the 
control  of  the  smoke  in  Pittsburgh. 

Dr.  Grayson: 

I  may  say  yes.  The  only  practical  work  has  been  done  thru  the  factory 
inspectors  appointed  by  the  city.  They  have  gone  with  the  manufacturers 
and  shown  them  the  actual  saving  by  the  use  of  the  smoke-saving  devices, 
and  that  they  can  use  fuel  more  economically  with  them.  There  are  plenty 
of  these  devices  and  they  are  good.  A  stoker  has  to  be  made  to  use  them  be- 
fore he  will  admit  their  advantage. 

Dr.  Marcy: 

Sometime  ago  I  heard  this  subject  discust  in  Boston.  The  illustration 
was  given  of  two  furnaces  just  alike :  upon  one  the  draft  was  up ;  on  the  other 
it  was  down.  In  one  year  there  was  a  saving  of  $750  with  the  furnace  in  which 
the  draft  was  down. 

Dr.  Thomas  Darlington,  New  York: 

Just  a  word  regarding  the  smoke.  We  have  no  smoke  in  Manhattan.  The 
only  way  to  stop  the  smoke  is  a  matter  of  arrest.  I  had  the  privilege  of  ar- 
resting 348  persons — some  of  them  my  best  friends — in  one  year. 

So  far  as  the  Compensation  Act  is  concerned,  I  would  not  care  to  discuss 
that.  The  State  of  New  York  gives  the  Commissioner  the  right  to  fix  the 
physician's  fees.  It  rests  with  the  physician  whether  he  will  get  along  with 
the  Commissioner  or  not.  Reasonable  fees  are  allowed  in  all  cases. 

I  was  interested  in  what  Dr.  Woods  Hutchinson  said  about  happiness.  It 
is  of  interest  that  during  the  Hudson-Fulton  celebration  the  record  of  suicides 
fell  to  one-half.  Dr.  Steiner  tells  the  story  of  a  man  who  had  made  sufficient 
in  Pittsburgh  to  go  home  and  buy  a  place  in  one  of  their  own  valleys.  He 
had  a  nice  home  but  did  not  enjoy  it.  Askt  why  he  wanted  to  go  back  to 
Pittsburgh  he  said:  "When  I  go  there,  big  boss  come  along  and  say,  'Hello 
Mike.'  "  And  that  was  happiness  to  Mike.  That  was  sufficient  to  leave 
Europe  and  come  to  this  country.  Speaking  of  these  plazas  and  squares 
where  the  people  meet,  there  is  a  place  in  New  York  where  300,000  Italians 
live  and  in  it  a  square  where  the  band  plays  and  they  wander  round  and 
round.  They  are  contented  because  they  have  that  square  to  wander  around 
and  get  acquainted. 

Regarding  cramps  in  the  steel  mills,  they  are  not  due  to  loss  of  body  fluids, 
but  due  entirely  to  the  temperature  of  the  water,  the  icing  of  water  affecting 
some  branch  of  the  pneumogastric  nerve.  A  circulating  supply  of  water  has 
been  put  in  at  Homestead  and  since  then  not  a  single  case  of  cramps  has 
occurred.  In  one  of  the  largest  mills  in  Pittsburgh  the  cost  of  supplying  the 
water  was  $22,500  a  year.  By  the  installation  of  the  circulating  supply 


179 

of  water  there  was  a  lessening  of  cost  of  $20,000  a  year,  so  that  in  a  few  years 
there  will  be  a  return  of  the  cost  ($145,000).     So  it  pays  financially. 

Regarding  the  question  of  pneumonia  in  these  workmen.  Away  back  in 
1 886  we  had  an  enormous  amount  of  lobar  pneumonia.  The  cases  came  from 
places  in  which  there  was  no  dust  or  smoke.  It  was  simply  a  question  of 
contagion  and  lack  of  resistance  on  the  part  of  the  worker.  In  the  cement 
mills  it  is  another  proposition.  Ordinarily  the  cause  lies  in  overcrowding, 
bad  food  and  alcohol  that  give  these  cases  of  pneumonia.  The  cases  are 
due  to  the  pneumococcus  rather  than  to  the  smoke.  There  is  a  list  of  sub- 
jects which  those  who  are  in  the  steel  industry  and  the  coal  mining  take  up, 
and  some  are  lookt  after  better  here  than  anywhere  else. 

Dr.  Woods  Hutchinson,  New  York : 

Is  it  not  true  that  those  devices  do  save  fuel  and  pay  the  manufacturers  in 
the  long  run? 

Dr.  Darlington: 

Yes  it  saves  him  money  in  the  proper  burning  of  the  fuel,  but  saves  him 
more  in  the  contentment  of  the  neighborhood. 

Dr.  Thomas  D.  Davis,  Pittsburgh: 

There  is  a  fact  that  I  want  to  mention  here :  When  the  ostrich  gets  scared 
it  hides  its  head  in  the  sand  and  thinks  no  one  sees  it.  This  is  about  true  in 
regard  to  smoke  consumption.  While  you  cannot  see  the  smoke  in  New  York, 
the  by-products  are  there  and  may  be  worse  than  the  smoke  you  can  see. 
Right  in  our  own  city  we  have  this  exemplified.  I  can  take  you  to  districts 
in  which  you  cannot  see  a  particle  of  smoke  and  yet  every  bit  of  the  vegeta- 
tion is  killed.  Anyone  who  has  used  anthracite  coal  knows  something  of  the 
gases,  and  that  they  are  more  deleterious  than  the  carbon  from  bituminous 
coal.  The  mere  fact  that  you  cannot  see  the  dust  in  the  air  is  no  evidence 
that  it  does  no  harm.  The  dust  from  smelting  iron  ore  is  almost  invisible. 
Yet  it  will  collect  on  roofs  and  porches  half  a  mile  away,  as  a  blighting  red 
dust.  It  does  not  follow  that  when  you  get  rid  of  the  carbon  you  get  rid  of 
all  the  deleterious  properties  from  furnaces. 

Regarding  the  steel  workers  and  their  use  of  ice-water,  they  use  almost  uni- 
versally oatmeal  water;  ice-water  is  not  supplied  to  the  men;  if  they  have 
ice-water  they  get  it  on  their  own  account.  Time  and  again  have  I  seen  the 
men  throw  a  pail  of  water  over  their  hot  bodies  and  go  back  to  the  heat. 
Altho  this  is  forbidden,  they  will  do  it  just  as  they  do  other  careless  things. 

Dr.  Edward  Jackson,  Denver: 

That  gases  may  be  more  deleterious  than  dust  is  probable,  but  we  must 
recognize  that  dust  also  may  be  dangerous.  The  most  striking  instance  of 
this  is  in  the  dust  of  the  quartz  especially,  particularly  in  Utah.  Dr.  Betts, 
in  working  up  statistics  of  a  certain  mill,  found  that  the  average  length  of 


i8o 

time  workmen  could  labor  there  was  14  months  and  that  in  four  and  one-half 
years  among  the  employees,  numbering  40  to  60  young  healthy  men,  there 
had  been  166  deaths  from  chronic  interstitial  pneumonia  induced  by  stone  dust. 
In  these  mills  there  were  no  fumes  and  no  gases.  But  there  was  an  extremely 
sharp,  angular,  very  fine  dust.  The  only  thing  that  has  made  it  possible  for 
men  to  continue  that  work  has  been  the  removal  of  that  dust  from  the  atmos- 
phere they  breathe. 

Dr.  Darlington: 

If  you  get  plenty  of  heat  you  burn  up  the  hydrocarbons  and  carbon  monoxid. 
It  is  not  the  product  of  the  carbon  that  you  save ;  it  is  the  product  of  the  carbon 
monoxid  in  all  low  combustion.  Where  they  use  cylinders  they  have  the  low 
form  of  combustion.  These  are  used  in  apartment  houses  where  they  do  not 
want  much  steam.  You  have  the  carbon  monoxid  come  out  of  the  chimney 
and  have  a  great  deal  of  hydrocarbons.  The  sulphuretted  hydrogen  which 
people  can  smell  they  think  much  more  detrimental. 

So  far  as  the  icing  of  water  in  mills  is  concerned,  the  ice  is  not  furnisht  by 
the  employer  but  I  have  seen  the  men  buy  it  themselves. 

Dr.  Davis: 

I  know  that  ice  used  in  the  mills  is  used  contrary  to  the  rules.  Those 
who  use  it  are  not  usually  the  steel  workers,  but  engineers  and  others  who  are 
not  exposed  to  so  great  heat.  Coal  is  not  used  in  the  production  of  steel  at 
all;  steel  is  made  absolutely  by  the  use  of  the  natural  gas  or  by  coal  turned 
into  gas.  The  deleterious  vapors  coming  from  steel  mills  are  not  connected 
above  with  the  coal.  The  fumes  from  smelters  of  zinc,  copper,  vanadium, 
etc.,  around  our  city  injure  vegetation  more  than  smoke,  yet  these  fumes  are 
almost  invisible. 

Dr.  James  H.  McBride,  Pasadena: 

We  had  an  interesting  instance  of  the  suppression  of  a  dust  nuisance  in 
Southern  California. 

The  owners  of  a  cement  manufactory  were  sued  by  orange  growers  for  dam- 
age done  to  their  trees  by  dust.  The  court  has  ordered  them  to  buy  the  orange 
groves  at  a  cost  of  $116,000  and  has  also  required  them  to  suppress  the  dust. 
This  has  been  done  principally  by  passing  it  thru  water  sprayed  into  a  large 
room.  The  dust  nuisance  at  these  works  has  been  practically  abated. 

Dr.  H.  M.  Hurd,  former  Superintendent  of  Johns  Hopkins  Hospital,  told 
me  they  had  gotten  rid  of  the  smoke  from  their  boiler  fires  by  using  smoke 
consumers.  They  put  a  smoke  consumer  in  each  of  their  fire  boilers  at  a 
cost  of  $500  apiece  and  the  first  year  the  saving  of  fuel  amounted  to  about 
$2,000. 

The  twelve-hour  day  for  workmen  has  been  demonstrated  to  be  injurious 
to  the  worker  and  unprofitable  for  the  employer.  At  the  Engis  Chemical 
Works  in  Belgium,  where  each  man's  product  could  be  measured  or  weighed, 


it  has  been  shown  that  the  men  can  do  as  much  work  in  eight  hours  as  they 
formerly  did  in  12.  The  Company  shortened  the  hours  and  required  the 
workmen  to  take  a  bath  after  the  day's  work  and  change  their  clothing. 
The  result  has  been  that  from  being  an  irregular  and  unreliable  class  of  workers 
they  now  remain  in  the  employ  of  the  Company.  Drunkenness  and  discon- 
tent have  ceased  and  the  Superintendent  says:  "In  the  eight-hour  day, 
representing  seven  and  one-half  hours  of  actual  work,  the  same  workmen  at 
the  same  ovens  with  the  same  implements  and  raw  materials,  produced  as 
much  as  previously  in  twelve  hours." 

The  Zeiss  Optical  works  at  Jena  reduced  the  hours  of  work  from  twelve 
and  ten  to  eight.  There  has  been  less  sickness,  less  falling  out  of  men  seeking 
change,  and  a  greater  average  output  per  man.  All  this  has  been  accomplisht 
without  "speeding  up"  and  has  resulted  in  a  healthier  and  more  contented 
class  of  workers. 

Mr.  John  Roach,  Trenton,  N.  J. : 

Regarding  the  dust  in  the  mills  of  California — did  they  protect  the  workers 
in  the  mills  as  well? 

Dr.  McBride: 

I  think  they  did  not  because  of  the  attitude  of  the  court. 


INDLX. 


Accidents,  Prevention  of  industrial — and  sickness  by  systematic  inspec- 
tion of  plant  and  employees.  H.  W.  Jordan,  B.S.  in  Chemistry,  Syra- 
cuse, N.  Y 109 

Bulkley,  L.  Duncan,  A.M.,  M.D.,  N.  Y.  City.  Fatigue  as  an  element 
of  menace  to  health  in  the  industries 44 

Cancer  death  rate  in  selected  occupations,  The — .  Frederick  L.  Hoff- 
man, LL.D.,  Newark,  N.  J £*  "7" 

Causes  of  morbidity  and  mortality  in  the  industrial  parturient  woman 
and  measures  for  improvement.  E.  E.  Montgomery,  M.D.,  Lit.D., 
Philadelphia < 40 

Child  labor,  Measuring  the  cost  of-rr-.  Owen  R.  Lovejoy,  LL.D.,  N.  Y. 
City 31 

Child  labor,  Measuring  the  cost  of — .  Alexander  J.  McKelway,  D.D., 
Washington,  D.C 31 

Compensation  acts,  The  relation  of  the  medical  profession  to  the  work- 
man's— in  the  United  States.  Frederick  L.  Van  Sickle,  M.D.,  Oly- 
phant,  Pa 145 

Crowding,  in  relation  to  the  health  of  working  people.  Charles  Rich- 
mond Henderson,  D.D.,  Ph.D.,  Chicago 61 

Davis,  Thomas  D.,  M.D.,  Ph.D.,  Pittsburgh.     Home  surroundings.  ...     82 

Discussion 92   1 75 

Drugs,  How  foods  and — can  menace.  Winfield  Scott  Hall,  Ph.D.,  M.D., 
Chicago 70 

Economic  importance  of  lead  poisoning,  The.  Alice  Hamilton,  M.A., 
M.D.,  Chicago 21 

Efficiency,  Happiness  as  a  factor  in — .  Woods  Hutchinson,  A.M., 
M.  D.,New  York  City 135 

Estes,  W.  L.,  A.M.,  M.D.,  South  Bethlehem,  Pa.  Industrial  injuries: 
treatment 139 

Factory  employees;  Health  measures  effecting — ,  some  remarks  on  the 
medical  phases  of  such  legislation.  J.  E.  Tuckerman,  A.B.,  M.D., 
Cleveland 126 

Fatigue  as  an  element  of  menace  to  health  in  the  industries.  L.  Duncan 
Bulkley,  A.M.,  M.D.,  N.  Y.  City 44 

Hall,  Winfield  Scott,  Ph.D.,  M.D.,  Chicago.  How  foods  and  drugs  can 
menace 70 

Hamilton,  Alice,  M.A.,  M.D.,  Chicago.  The  economic  importance  of 
lead  poisoning 21 

Happiness  as  a  factor  in  efficiency.  Woods  Hutchinson,  A.M.,  M.D., 
New  York  City 135 


Health,  Fatigue  as  an  element  of  menace  to — in  the  industries.  L. 
Duncan  Bulkley,  A.M.,  M.D.,  New  York  City 44 

Health  measures  effecting  factory  employees;  some  remarks  on  the  med- 
ical phases  of  such  legislation.  J.  E.  Tuckerman,  A.B.,  M.D.,  Cleve- 
land   I26 

Heat  and  ventilation.     John  Roach,  Trenton,  N.  J 56 

Henderson,  Charles  Richmond,  D.D.,  Ph.D.,  Chicago.  Crowding,  in 
relation  to  the  health  of  working  people 61 

Hoffman,  Frederick  L.,  LL.D.,  Newark,  N.  J.  The  cancer  death  rate 
in  selected  occupations 7 

Home  surroundings.     Thomas  D.  Davis,  M.D.,  Ph.D.,  Pittsburgh 82 

How  foods  and  drugs  can  menace.  Winfield  Scott  Hall,  Ph.D.,  M.D., 
Chicago 7o 

Hutchinson,  Woods,  A.M.,  M.D.,  New  York  City.  Happiness  as  a  fac- 
tor in  efficiency 135 

Hygiene  and  machinery  hazards.  C.  T.  Graham-Rogers,  M.D.,  N.  Y. 
City 27 

Improper  recreations.     Sherman  C.  Kingsley,  Chicago 87 

Industrial  accidents,  Prevention  of — and  sickness  by  systematic  inspec- 
tion of  plant  and  employees.  H.  W.  Jordan,  B.S.  in  Chemistry,  Syra- 
cuse, N.  Y 109 

Industrial  injuries:  treatment.  W.  L.  Estes,  A.M.,  M.D.,  South  Beth- 
lehem, Pa 139 

Industries,  Fatigue  as  an  element  of  menace  to  health  in  the — .  L. 
Duncan  Bulkley,  A.M.,  M.D.,  N.  Y.  City 44 

Industries,  Light  in  the — .     Edward  Jackson,  M.D.,  Denver 50 

Industries,  Medical  inspection  of  the — ,  — national,  state,  municipal  or 
private.  Ray  Lyman  Wilbur,  A.M.,  M.D.,  San  Francisco 98 

Introduction 3 

Jackson,  Edward,  M.D.,  Denver.     Light  in  the  industries 50 

Jordan,  H.  W.,  B.S.  in  Chemistry,  Syracuse,  N.  Y.  Prevention  of  in- 
dustrial accidents  and  sickness  by  systematic  inspection  of  plant  and 
employees 109 

Lead  poisoning,  The  economic  importance  of — .  Alice  Hamilton,  M.A., 
M.D.,  Chicago 21 

Light  in  the  industries.     Edward  Jackson,  M.D.,  Denver 50 

Lovejoy,  Owen  R.,  LL.D.,  N.  Y.  City.     Measuring  the  cost  of  child  labor.     31 

Lowman,  John  B.,  M.D.,  Johnstown,  Pa.  Rules  and  regulations  in  opera- 
ting plants — carelessness  and  recklessness." 114 

McKelway,  Alexander  J.,  D.D.,  Washington,  D.C.  Measuring  the  cost 
of  child  labor 31 

Machinery  hazards,  Hygiene  and — .  C.  T.  Graham-Rogers,  M.D., 
N.  Y.  City 27 

Measuring  the  cost  of  child  labor.     Owen  R.  Lovejoy,  LL.D.,  N.  Y.  City.     31 


Measuring  the  cost  of  child  labor.  Alexander  J.  McKelway,  D.D., 
Washington,  D.  C 31 

Medical  inspection  of  the  industries — national,  state,  municipal  or  pri- 
vate. Ray  Lyman  Wilbur,  A.M.,  M.D.,  San  Francisco 98 

Medical  profession,  The  relation  of  the — to  the  workman's  compensation 
acts  in  the  United  States.  Frederick  L.  Van  Sickle,  M.D.,  Olyphant, 
Pa 145 

Medical  supervision  in  dangerous  trades.  George  M.  Price,  M.D., 
New  York  City 103 

Montgomery,  B.  E.,  M.D.,  LL.D.,  Philadelphia.  Causes  of  morbidity 
and  mortality  in  the  industrial  parturient  woman  and  measures  for 
improvement 40 

Morbidity,  Causes  of —  and  mortality  in  the  industrial  parturient  woman 
and  measures  for  improvement.  B.  B.  Montgomery,  M.  D.,  LL.D., 
Philadelphia 40 

Mortality,  Causes  of  morbidity  and —  in  the  industrial  parturient  woman 
and  measures  for  improvement.  B.  B.  Montgomery,  M.D.,  LL.D., 
Philadelphia 40 

Occupations,  The  cancer  death  rate  in  selected — .  Frederick  L.  Hoff- 
man, LL.D.,  Newark,  N.  J 7 

Parturient  woman,  Causes  of  morbidity  and  mortality  in  the  industrial — 
and  measures  for  improvement.  B.  B.  Montgomery,  M.D.,  LL.D., 
Philadelphia 40 

Plants,  Rules  and  regulations  in  operating — ,  — carelessness  and  reckless- 
ness. John  B.  Lowman,  M.D.,  Johnstown,  Pa 114 

Prevention  of  industrial  accidents  and  sickness  by  systematic  inspection 
of  plant  and  employees.  H.  W.  Jordan,  B.S.  in  Chemistry,  Syracuse, 
N.  Y 109 

Price,  George  M.,  M.D.,  New  York  City.  Medical  supervision  in  danger- 
ous trades 103 

Recreations,  Improper — .     Sherman  C.  Kingsley,  Chicago 87 

Relation  of  the  medical  profession  to  the  workman's  compensation  acts 
in  the  United  States,  The.  Frederick  L.  Van  Sickle,  M.D.,  Olyphant, 
Pa 145 

Roach,  John,  Trenton,  N.  J.     Heat  and  ventilation 56 

Rogers,  C.  T.  Graham-,  M.D.,  N.  Y.  City.  Hygiene  and  machinery 
hazards 27 

Rules  and  regulations  in  operating  plants — carelessness  and  recklessness. 
John  B.  Lowman,  M.D.,  Johnstown,  Pa 114 

Sickness,  Prevention  of  industrial  accidents  and — by  systematic  inspec- 
tion of  plant  and  employees.  H.  W.  Jordan,  B.S.  in  Chemistry, 
Syracuse,  N.  Y 109 

Table  of  contents 5 

Trades,  Medical  supervision  in  dangerous — .  George  M.  Price,  M.D., 
New  York  City 103 


**$ 

Tuckerman,  J.  E-,  A.B.,  M.D.,  Cleveland.  Health  measures  effecting  fac- 
tory employees;  some  remarks  on  the  medical  phases  of  such  legislation.  126 

United  States,  The  relation  of  the  medical  profession  to  the  workman's 
compensation  acts  in  the — .  Frederick  L.  Van  Sickle,  M.D.,  Oly- 
phant,  Pa 145 

Van  Sickle,  Frederick  L.,  M.D.,  Olyphant,  Pa.  The  relation  of  the  medical 
profession  to  the  workman's  compensation  acts  in  the  United  States. .  145 

Ventilation,  Heat  and — .     John  Roach,  Trenton,  N.  J 56 

Wilbur,  Ray  Lyman,  A.M.,  M.D.,  San  Francisco.  Medical  inspection 
of  the  industries — national,  state,  municipal  or  private 98 

Working  people,  Crowding  in  relation  to  the  health  of — .  Charles 
Richmond  Henderson,  D.D.,  Ph.D.,  Chicago 61 

Workman's  compensation  acts,  The  relation  of  the  medical  profession  to 
the— hi  the  United  States.  Frederick  L.  Van  Sickle,  M.D.,  Olyphant, 
Pa 1 45 


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